THEORIES OF PSYCHOPATHOLOGY
PSYCHOLOGY 341 (L01)
CULTURE AND PSYCHOPATHOLOGY
Welcome to a very exciting course. In this course we will travel around the world to explore the description, prevalence and treatment of mental illness in different cultures. We will also be exploring culture-specific (unique to the culture) psychological syndromes.
COURSE OUTLINE
Instructor: Dr Assen Alladin
Phone: 670-1340
Office: Department of Psychology, Foothills Hospital
1403-29 Street N.W., Calgary, Alberta T2N 2T9
Telephone : (403) 670-1340 Fax : (403) 670-2060
E-mail : dralladin@
Web Page : CollegePark/Gym/7210/
Hours: By appointment
Text: Al-Issa, I. (1995). Handbook of culture and mental illness. Madison: International
Universities Press.
LECTURE DAYS/TIME/PLACE: Refer to Course Outline
COURSE CONTENTS: Refer to Course Outline
ASSIGNMENTS/EXAMS: Refer to Course Outline
Chapter 1
CULTURE AND PSYCHOPATHOLOGY:
AN INTERNATIONAL PERSPECTIVE
Instructor: Dr Assen Alladin
Lecture Outline
1. Definition of culture
2. Historical developments of the study of culture and psychopathology
3. Politics of psychiatric diagnosis
4. Politics of deinstitutionalization
5. Psychopathology among different nations
(a) acute reactive psychosis
(b) schizophrenia
© depression and suicide
(d) somatization disorder
(e) alcoholism
(f) mental health among immigrants and ethnic
minorities
6. Culture-Specific Syndromes
7. Cultural epidemiology
8. Conclusions
1. Definitions of Culture
1.(i) Definitions of culture
Definition consists of subjective and objective characteristics of human-made environment.
Subjective environment:
- beliefs
- values
- norms
- myths
Objective characteristics:
- physical environment
- roads
- bridges
- buildings
Culture is the way of life of a particular society or group of
people, including patterns of thought, beliefs, behavior,
customs, traditions, rituals, dress, and language, as well as
art, music, and literature. (Webster’s New World Encyclopedia, 1992)
Shared patterns of belief, feeling and adaptation which
people carry in their minds. (Leighton & Hughes, 1961)
Culture is an organized group of ideas, habits and
conditioned responding shared by members of a society. (Linton, 1956)
A blueprint for living. (Kluckholm, 1944)
1.(ii) Culture and Race
Culture often confused with race.
Race is a socially constructed category, which specifies
identification of group members.
Application of race in a social context is called racism.
Ethnic groups are individuals with a sense of belongingness
and are thought by themselves and/or by others to share a
common origin as well as an important segment of a common
culture.
The bond that brings members of an ethnic group together
may be defined in terms of physical appearance (race) and/or
social similarity (culture).
In psychiatry culture is equated with nation.
1.(iii) Cultural Psychiatry
Cultural psychiatry is a branch of social psychiatry which
“concerns itself with cultural aspects of the etiology,
frequency and nature of mental illness and the care and
aftercare of the mentally ill within the confines of a given
cultural unit.”
Wittkower, 1965
Since psychiatry itself is a part of Western culture, the
transcultural perspective starts from the Western cultural
base.
Cross-cultural studies too make assumptions derived from a
particular cultural base - usually the Western. Hence, the
term cultural and transcultural are usually used
synonymously.
2. Historical Developments in the Study of Cultural
Psychopathology
(a) Emil kraeplin (1856-1926), German Psychiatrist, well-known for the classification of mental disorders
Early 1900s observed incidence and symptomatology of
Western mental disorders (e.g., depression, schizophrenia) in Southeast Asia
Found their existence but different incidence and
symptoms
(b) Also observed culture-specific syndromes such as amok
(senseless killings) and latah (fright neurosis)
Concluded they are similar to hysteria, catatonic
episodes, epileptic twilight, etc.
© Also found different morbidity in Germany, France,
Italy and England
Concluded that Western disease entities are universal
(biological orientation)
(d) Sparked research in area of culture and mental illness
but undermined cultural uniqueness
(e) Questions asked:
(1) Are concepts of mental illness and the
Western system of psychiatric diagnosis
universal and applicable to other cultures?
(2) Are the incidence and symptoms of mental
illness the same across cultures?
(3) If culture-specific syndromes do exist, are
they the same types of syndromes familiar to
Western Psychiatrists, but merely expressed
differently, or do they represent different
psychiatric entities?
(f) Studies Conducted:
1930s:
Anthropologists Malinowsky and Benedict tested
“Nature cult” hypothesis: Increase of insanity in
Europe is due to degeneration of moral virtues.
Freudian hypothesis: Mental illness results from
a conflict between instinctual drives and the
repressive process of civilization.
Cross-cultural hypothesis: Non-Western style of
life provides immunity against mental illness.
Benedict & Jacks (1954) – no evidence
Conclusion: Major psychoses occur in all
societies
(f) Studies Conducted Cont/d.
1940s:
US and other parts of world survey mental illness
from hospital records to determine epidemiology
1st and 2nd generation immigrants show different
morbidity from native-born Americans and
Europeans
1950s:
Community studies
Rates of mental illness similar despite wide
differences in cultures
But cultural variability in symptoms
e.g., in East Africa: “going naked” = psychotic
behavior West: murder or serious assault = mental
illness
No psychotic hallucinations in East Africa
(f) Studies Conducted Cont/d.
1960s:
Validity of psychiatric diagnosis questioned
2 models of criticism:
(1) Social model (cultural relativity perspective)
Normality and abnormality defined within a social
and cultural context
Mental illness cannot be only medical or scientific
Moral, religious, or political factors involved
(2) Psychological model (dimensional approach)
Eysenck used statistical (factor) analysis to
identify a limited number of dimensions in order
to describe patients in terms of their position on
dimensions such as psychotism and neuroticism
Both models questioned the concept of mental illness as
an absolute entity that is qualitatively different from a
state of health.
Both brought problems related to diagnosis and
institutionalization.
3. Politics of Psychiatric Diagnosis
a. Kramer (1969) found differences in first-admission rates to mental hospitals in US and UK (per 100,000)
US UK
Schizophrenia 24.7 17.4
Affective psychosis 11.0 38.5
b. Led to US-UK Diagnostic Project and found differences due to:
(1) Different diagnostic concepts used
(2) Bleuler’s concept of schizophrenia not influential
in UK
(3) Psychoneurotic, pseudopsychopathic, simple,
borderline, and latent schizophrenia less used in
UK
(4) Early childhood autism differentiated from schizophrenia, not incorporated, in UK
(5) Freudian intrapsychic processes (projection, primary process) applied to concept of psychoses in US
c. Criticisms led to:
(1) Psychometric diagnosis consolidated in 1970s
(2) Reliable and valid diagnostic criteria based on
clearly defined symptoms, involving minimal
etiological inferences
(3) Semi-structured interviews to obtain person’s
history, social functioning, and symptom sates,
e.g., Schedule for Affective Disorders and
Schizophrenia (SADS), NIMH Diagnostic
Interview Schedule (DIS), Structured Clinical
Interview for DSM-III (SCID)
(4) Operational criteria for assigning persons to
diagnostic categories specified (adopted in
DSM-III)
(5) Political abuse of psychiatry in Soviet Union
(a) Soviet diagnostic criteria for schizophrenia
included mild (abstention from alcohol or
smoking, sustained energy level) and
moderate (paranoid – delusion of reformism,
heightened self-esteem) symptoms not
internationally accepted
(b) Antipsychotics used to treat “delusions of
reformism”, “anti-Soviet thoughts” in
absence of psychotic ideation
© Higher doses of neuroleptics in absence of
psychotic symptoms
4. Politics of Deinstitutionalization
a. Deinstitutionalization of long-term in-patients in the
1960s
In US in 1955: 559, 000
1990: 110,000
b. Reasons for deinstitutionalization
(1) Better diagnosis and classification
(2) introduction of phenothiazines
(3) institutional neurosis
(4) better outcomes for community programs
c. Problems with deinstitulionalization
(1) some psychotics and personality disorders require custodial care
(2) sick young adults uncooperative
(3) high risk of schizophrenia and drug abuse
(4) inadequate community resources
(5) loss of funds, benefits
(6) 25-50% of homeless mentally ill
(7) increase of cardiovascular disorders (UK,US and Denmark)
5. Traditional-Modern Continuum of Cultural Styles
________________________________________________________________________
Domain Traditional Culture Modern Culture
________________________________________________________________________
1. Gender role Strict distinctions Flexible boundaries
2. Family identity Family loyalty and Individual values
identification
3. Sense of community Strong sense of Individualism
community emphasized
4. Time orientation Strong sense of Future orientated
past and present
5. Age status Aging wisdom Value vitality of youth
6. Tradition Reinforce history Barrier to progress
with ceremony
7. Convention and Socialized to follow Encouraged to
authority and respect norms authority
________________________________________________________________________
6. Psychopathology Among Different Nations
a. Acute reactive psychosis
Psychotic reactions with short duration and complete
recovery in non-Western countries, e.g., India, Bali,
Jamaica, Tanzania, Nigeria
bouffee delirante (Francophone, more among uneducated)
In Anglo-European colonies
fear psychosis
anxiety psychosis
epileptic twilight states
confusional periodic psychoses
Similar to psychogenic or reactive psychosis and
schizophreniform psychoses in Anglo-Saxon and
Scandinavian countries
National/cultural interpretation/causes
UK : organic factors, e.g., infection
Germany : organic factors
US : acute, transient, chronic, reactive
(Bleuler)
Scandinavia : differentiate “psychogenic” and
chronic
France : constitutional predisposition
Implications
(1) acute reactive psychosis may be confused with schizophrenia
(2) skew international research
(3) reported prognosis artifact of inclusion of acute cases
6 (b). Schizophrenia
(1) Sociocultural factors determine prevalence
(a) Few cases among Maoris, Hawaiians, Manu’a
(b) Significant increase after the 1950s
© Currently low among
Hutterites (1.9/1000)
South Pacific Tongans (1.0/1000)
Taiwan aboriginal tribes (0.6/1000)
Contrasting cultural background, but
communalistic style of living
(d) Currently high among
Irish
Istrians (in Croatia)
Selection hypothesis applicable to Istrians
(“sick” people remaining)
(2) Changing Picture of Schizophrenia
(a) Western world (US, Germany, UK)
Decrease in incidence of severe subtypes
e.g., catatonia
Increase in paranoid subtype
(b) Developing countries
Severe types of schizophrenia relatively
high, e.g., catatonia
India (Agra, Cali) : 22%, 13%
Sri Lanka : 21%
Egypt : 14.4%
Ibadan : 8%
6 (b) Schizophrenia Cont/d.
Why this shift from severe to mild?
Why the shift from physical expression to cognitive?
(3) Chronicity and Course of Schizophrenia
(a) Poorer prognosis, more chronicity in
industrialized countries such as UK, Denmark,
US, Czech Republic
(b) Better prognosis in Nigeria, India, Sri Lanka
© Due to social rejection, assignment of
responsibility, social networks
(4) Expressed Emotions and Outcome
(a) High Expressed Emotions (EE) related to relapse
(b) High EE: critical comments of relatives
high degree of hostility
emotional involvement
© Cultural variations in EE
(d) Western acceptance of negative symptoms
(e) Non-Westerners show more tolerance and
extended family involvement
6. Psychopathology Among Different Nations Cont/d.
6 © Postpartum psychosis
More prevalent among African women
Senegal : 30% of psychiatric admission
North Africa : 10-15%
Western : 4-5%
Possible reasons:
(1) symptoms heterogeneous
(2) may reflect affective disorder, organic psychosis,
or schizophrenia
(3) predominance schizophrenic-like symptoms in
Africa (West: 2-16% of patients; Africa: 24-53%)
(4) symptoms mobilize community support in Africa
(5) in West patient has to function independently of
group
7. Cultural Epidemiology
The study of diseases and other health-related characteristics
in a given population or nation or with several nations.
What is the etiology of the condition?
Which groups in the population are most at risk?
How effective are various efforts at treatment or prevention?
What is the finical and social cost of the disease?
Two basic sets of data from epidemiological survey research:
(1) Prevalence of disorders: how many persons in a population with a particular diagnosis - rate per 100,000
(2) Their incidence: prevalence within a given period of
time
Problems with cultural epidemiological studies
Data concerned with international variation of rates of mental
illness, but these rates may not represent true prevalence
because of:
Problems with cultural epidemiological studies Cont/d.
1. Unreliability of psychiatric diagnosis (universal but perceptual bias)
2. Professional training
3. Cultural background of researcher
4. Availability of psychiatric services
5. Degree of tolerance to symptoms
6. Psychiatric services restricted to minority
7. Alternative native treatment by majority
8. Response to treatment
9. Estimation of relationship between incidence and population characteristics (age, sex, race, etc.) problematic
10. Quality of different surveys makes comparison difficult
11. “Carriers” of mental disorders cannot be isolated and quarantined - cannot identify causes with precision
MODELS AND FORMS OF MAJOR PSYCHOPATHOLOGIES
1. The Organic-Medical Model
1. An organic cause
- underlying pathology causing the “disease”
- infection, tissue damage, metabolic disorder
- e.g., schizophrenia, manic-depressive psychosis
2. Specific diagnostic methods
- diagnosis based on signs and symptoms
- reflection of underlying organicity
- observation
3. Specific approach to treatment
- rooting out underlying causes
- medication
- physical treatment
MODELS OF PSYCHOPATHOLOGY CONT/D.
Advantages of the Medical Model
1. Major step forward - took away moral responsibility
2. Reduced disgrace - “humanization” of mental hospitals
3. Encouraged empirical research
4. Objective observation of abnormal behavior
5. Raised occupational standing
Disadvantages of the Medical Model
1. Classification according to abnormal behavior, not response
to therapy
2. Treatment in mental hospitals
3. Primary prevention in schools, home, community
MODELS OF PSYCHOPATHOLOGY CONT/D.
2. The Dynamic Model
(1) Interaction during early childhood
(2) Stages of psychosexual development - oral, anal, and phallic
Advantages of the Dynamic Model
(1) Did not place responsibility on either sin, weak will, or tissue
damage
(2) Blamed family, friends, and physiology
(3) Broadened the search for causation
Disadvantages of the Dynamic Model
(1) Adherence to predictive validity of events in early life
(2) Validity of such predictions cannot be tested empirically
(3) After the facts crucial negative events highlighted
MODELS OF PSYCHOPATHOLOGY CONT/D.
3. The Behavioral Model
(1) Learned maladaptive behaviors
(2) Treatment derived from learning principles
(3) Adoption of more adaptive behaviors
Advantages of the Behavioral Model
(1) Explains the development and maintenance of symptoms
(2) Plausible model of nonpsychotic disorders
(3) Amenable to empirical validation
(4) Structure to assessment and treatment
Disadvantages of the Behavioral Model
(1) Humans seen as passive
(2) Thinking undermined
(3) Cannot explain psychotic disorders satisfactorily
MODELS OF PSYCHOPATHOLOGY CONT/D.
4. Cognitive Model of Psychopathology
(1) Thinking determines feeling
(2) Cognitive distortions lead to symptoms
(3) Focus on description of symptoms
(4) Structured assessment and treatment
Advantages of the Cognitive Model
(1) Focus on therapy rather than etiology
(2) Empirically derived theory
(3) Empirical validation of theory
(4) Empirical validation of outcome
(5) Flexible to integrate with other theories
Disadvantages of the Cognitive Model
(1) Treatment time-consuming
(2) Some educational level required
MODELS OF PSYCHOPATHOLOGY CONT/D.
5. The Moral Model
(1) Supernatural forces responsible for disordered behaviors
(2) Resulting from sin and moral transgression
(3) Devil and his demons and witches responsible
(4) Exorcism, burning, magical potions to purge evils out
(5) Search for demon possession - The Witches’ Hammer (1487)
6. The Social-Consequence Model (Thomas Szasz)
(1) Problems of living
(2) Medication cannot solve problems of living
(3) Acceptance of personal responsibility
(4) Importance of environment
7. The Legal Model
(1) Responsibility for criminal acts
(2) Civil rights designated for mentally challenged and
mentally ill
DSM-IV
(DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDER) CLASSIFICATION OF MENTAL DISORDERS
1. Anxiety Disorders
(a) Characteristic Symptoms
(1) Cognitive distress, distortions, and ruminations
(2) Physiological arousal
(3) Behavioral disruptions and avoidance
(b) Types of Anxiety Disorders
(1) Panic disorder, with or without agoraphobia
(2) Specific phobia (e.g., fear of flying, bee, snake)
(3) Social phobia (Social anxiety disorder)
(4) Obsessive-compulsive disorder (OCD)
(5) Posttraumatic stress disorder (PTSD)
(6) Acute stress disorder
(7) Generalized anxiety disorder
(8) Anxiety disorder due to medical condition
(9) Substance-induced anxiety disorder
2. Dissociative and Somatoform Disorders
2 (1). Dissociative Disorders
(a) Characteristic Symptoms of Dissociative Disorders
(1) Amnesia: loss of memory
(2) Depersonalization: feelings of detachment
(3) Derealization: strange or unreal feelings
(4) Identity confusion: uncertainty of one’s own identity
(5) Identity alteration: patterns of behavior adopting new identity
(b) Types of Dissociative Disorders
(1) Dissociative identity disorder (previously MPD)
(2) Dissociative amnesia
(3) Dissociative fugue
(4) Depersonalization diosrder
2(2). Somatoform Disorders
(a) Characteristic Symptoms
(1) Psychological distress presented via physical symptoms
(2) Sensitivity or preoccupation with bodily cues
(3) Misinterpretation of emotions as signs of physical illness
(b) Types of Somatoform Disorders
(1) Somatization disorder (Briquet’s syndrome)
(2) Hypochondriasis
(3) Conversion disorder (la belle indifference)
(4) Pain disorder
(5) Body dysmorphic disorder
3. Mood Disorders and Suicide
3(1) Mood Disorders
(a) Characteristic Symptoms
(1) Depressed mood persists for weeks
(2) Severe, impairs social and occupational activities
(3) Present vegetative (physical and behavioral) symptoms
(4) Elation and expansive ideas in bipolar disorder
(b) Types of Mood Disorders
(1) Major depressive disorder
(2) Dysthymic disorder
(3) Bipolar disorder
3. Mood Disorders and Suicide Cont/d
3(2) Suicide
(a) Characteristic Symptoms
(1) Feelings of hopelessness
(2) Determined to die
(3) Associated with hurt and/or mental illness
(b) Types of suicidal behavior
(1) Parasuicide
(2) Completed suicide
© Key Risk Factors for Suicide
(1) Patient with depression, alcoholism or schizophrenia
(2) Male
(3) Elderly
(4) European American background
(5) History of prior suicide attempts
(6) Experiencing stressful life events, e.g., loss
4. Schizophrenia
(a) Characteristic Symptoms
(1) Delusions (misinterpretation of perceptual experiences)
(2) Hallucinations (can’t discriminate between real events)
(3) Disorganized speech
(4) Grossly disorganized or catatonic behavior
(5) Negative symptoms (flat affect, alogia, avolition)
(b) Types of Schizophrenia
(1) Paranoid type (e.g., delusion of persecution)
(2) Disorganized type (hebephrenia)
(3) Catatonic type (odd motor movements, waxy flexibility)
(4) Undifferentiated type (no specific criteria)
(5) Residual type (in remission)
© High Expressed Emotion (High EE)
- Related to relapse rate (Low EE: 21, High EE: 48)
5. Personality Disorders
(a) Characteristic Symptoms
(1) Ego-syntonic: denies problems, sees self as normal
(2) Difficult to treat: blames others
(3) More distressing for others
(4) Comorbid with other psychological disorders
(b) Types of Personality Disorders
(1) Paranoid Personality Disorder
(2) Schizoid Personality Disorder
(3) Schizotypal Personality Disorder
(4) Antisocial Personality Disorder
(5) Borderline Personality Disorder
(6) Histrionic Personality Disorder
(7) Narcissistic Personality Disorder
(8) Avoidant Personality Disorder
(9) Dependent Personality Disorder
(10) Obsessive-Compulsive Personality Disorder
6. Substance-Related Disorders
(a) Characteristic Symptoms
(1) Tolerance (increased need, decreased effect)
(2) Withdrawal symptoms (more use for relief)
(3) Larger amount consumed than intended
(4) Persistent desire or unsuccessful efforts to cut down
(5) Great deal of time and efforts to obtain
(6) Important activities given up or reduced
(7) Continued despite serious physical and psychological problems
(b) Types of Substance-Related Disorders
(1) Alcohol-Related Disorders
(2) Other depressants (barbiturate, benzodiazepines)
(3) Stimulants (amphetamine, cocaine, caffeine, nicotine)
(4) Opioids (narcotics e.g., heroin, morphine)
(5) Cannabis and hallucinogens (marijuana, LSD)
Chapter 2
TRANSCULTURAL PSYCHIATRY IN EGYPT
General Points
6. Non-medical healers treat conversion and dissociative disorders
7. Religious healers prescribe “hegab” (reading of sacred writing)
8. Religious healers also refer patients to a “sheikh” or a priest
9. El-Zar ceremony popular among uneducated and lower middle class
women
- El-Zar originated from Sudan
- Non-religious ceremony
- Gathering of women, headed by a “Kodia”
- Cause of illness attributed to “djenne”
- Exorcize the evil spirit or “djenne”
- Zar healers well-known among the people
- Usually conducted at the Kodia’s home
TRANSCULTURAL PSYCHIATRY IN EGYPT
General Points Continued
10. Relatives of psychiatric patients attribute causes to
- magic
- rage of God
- spirit
- envy
- supernatural forces
- demons
11. Folk prescriptions include
- drinking or bathing in water prepared by witches
- covering the patient’s head and body with blood from
selected pigeons, hens, duck, geese, roosters, etc.
12. Medical help as a last resort
13. Alcoholism not a major psychiatric problem
KNOWLEDGE AND ATTITUDES OF RELATIVES IN EGYPT
1. Mental illness seen an emotional crisis caused by external factors
- bereavement
- financial problems
- overwork
- failure in school
(maintain self-esteem and reduce guilt)
2. Relatives associate mental illness with
- meaningless speech
- patient talking to self
- violence
- excitement
- bizarre behavior
- hallucinations
- aimless walking
- strange body movements
- overall appearance
3. Relatives deny mental illness in family
- reject idea
- hide symptoms
- secrecy
- despair when cannot hide
- attempt to prevent adverse reactions from others
PSYCHIATRIC SERVICES FOR CHILDREN AND ELDERLY IN EGYPT
1. Children (0 - 6 years) 40% of population
2. Children affected (anxiety) by hospital admission
3. Common manifestations of anxiety
- fear of injections
- irrational fear of ghosts
- anorexia
- reduced activity
- sleep disturbances
- poor relationship with others
4. Elderly cared for at home (religious obligation)
TRANSCULTURAL STUDIES IN EGYPT
1. Schizophrenia
a) Rank correlation between Egypt and Britain higher (0.829) than
between Egypt and U.S.A. (0.625)
b) “Incongruity of affect” ranked first in Egypt
c) “Apathy” ranked eighth in Egypt
d) “Thought disorder” ranked second in Egypt
e) “Incoherence” ranked fifth in Egypt
TRANSCULTURAL STUDIES IN EGYPT CONT/D.
2. Depression
a) Somatic symptoms and anxiety higher in Egyptians and Indians
- incapacity to verbalize feelings
- lower social class and lower education
- physicians expect physical symptoms in “illness”
- personality factors
b) Suicidal ideation higher than suicide rate and attempted suicide
- family cohesion
- lack of social alienation
- religious condemnation
- lack of social acceptance
c) Guilt feelings low in Egyptian sample
- guilt externalized
Chapter 3
PSYCHIATRY IN NIGERIA
Geography
- in West Africa
- semi-desert (north) to tropical forest (south)
- multiethnic, 80 million
- over 200 linguistic groups
- 3 main ethnic groups:
Hausa (north) - predominantly Muslims
Igbos (southeast) - predominantly Christians
Yoruba (southwest) - predominantly Christians
- most people live in rural areas, mainly farmers
- literacy 40% of total population
- 60% population under 20 years of age
- free universal primary education
CULTURAL BACKGROUND OF MENTAL HEALTH IN NIGERIA
- before colonization mental illness treated by traditional healers
- etiology attributed to beliefs
- Ibadan Survey:
curses : 76%
epidemic infections : 67%
spirits : 47.2%
- genetic factors taken seriously, family investigation before marriage
- traditional treatment first before seeking hospital care
40% - Ibadan University College Hospital
TRADITIONAL CAUSES AND TREATMENT IN NIGERIA
________________________________________________________________________
Causes Treatment
________________________________________________________________________
Indigenous theories
Demonology and possession by Flogging, ritual offering of sacrifices
evil spirits to win divine favor
Offenses against gods Penitence and appeasement by offering sacrifices
Drugs (orally or parenterally)
Violent patients tied, handcuffed or chained (high mortality rate - 20%)
Prolonged “hospitalization” of chronics in healer’s compound
Islamic approach
Possessed by bad spirits Repeated prayers, “ink solution”, charms and amulets (drive away bad spirits and fortify,
surround by good)
Christian approach
Possession by bad spirits Fasting, prayers, “holy water” (extrapyramidal), prayers and night vigil (drums) for
cathartic effect, trance (speak in tongues)
________________________________________________________________________
MODERN MENTAL HEALTH SERVICES IN NIGERIA
- Mixture of traditional and modern practices
- Hospital admission as a last resort
- Acute phases remit before hospital visit
- Western psychiatry introduced in 1907, medical staff in 1927
( Yaba asylum - mainly custodial care)
- First modern psychiatric hospital in 1954 (insulin coma, ECT, barbiturates)
(tertiary care - 80%)
- 67 psychiatrists serving 80 million people
EFFECT OF CULTURE ON NIGERIAN MENTAL HEALTH
- Nomadic Fulanis highest rate of hospitalization for psychiatric disorders
(25.1% admissions although only 4% of the population)
Schizophrenia 41.2%
Affective disorders 29.9%
- Related to stress (constantly moving, locating grazing areas without conflict,
burning of forests and farm lands after harvesting the crops)
DEPRESSIVE DISORDERS IN NIGERIA
Symptoms of depression
- Asthenia
- Multiple hypochondriacal symptoms
- Mental inertia
- Personal decay
- Decline
- Retardation
- Cessation of bodily functions
- Description according to myths and symbols acceptable
claims of being a witch
crawling sensation in the body
feeling of bodily heat (central heat syndrome)
- Auditory and persecutory hallucinations
- Guilt feelings rare
- Lacking cognitive triad
- Suicide rare
CULTURE-SPECIFIC SYNDROME IN NIGERIA
- “Missing genitals”
- After encounter with a stranger genitals of one party disappears
- In women breast “stolen or changed”
- Objective examination reveal intact genital/breast
- Subjective reports of “different” after the greeting
- Anorexia nervosa non-existent
Chapter 4
PSYCHIATRY IN SOUTH AFRICA
Introduction
- Heterogeneous country
African origin 75% (e.g., Zulu, Xhosa)
Europeans (Whites)
Asians (Indians)
Coloureds (don’t fit other categories, e.g., mixed, Malay)
- Polylingual
African native speakers (many languages)
From different cultural groups
White Africans (English and Afrikaans)
- Cultural groups politically defined
- Psychiatric studies confined to native Africans
POLITICS OF CULTURE AND MENTAL ILLNESS IN SOUTH AFRICA
- Apartheid system based on cultural differences
- 14 separate department of health, each catering for a
separate cultural group
- Gross discrimination and disparities in services
- Political ideology profoundly affected nature of knowledge
racist orientation
lack of assertion in liberals
INDIGENOUS MENTAL ILLNESS AND HEALING IN SOUTH AFRICA
- Ngubane (1977) distinguishes between diseases of the African people
(ukufa kwabantu) and universal illnesses
Amafufunyane (possession by bad spirit)
Symptoms: Xhosa-speaking woman talking in Zulu in a male voice
Causes:
Bewitchment (ubuthakathi)
Negative relationship with one’s ancestors
Often both
Associated with social stressors
Treatment:
Treated either by a herbalist/doctor (inyanga in Zulu) or a diviner
(sanigoma in Zulu) or a faith healer
Herbalists: train by 1 year apprenticeship
Diviner: having gone through spirit possession (ukuthwasa)
Faith healers: African Independent churches
Zionist churches
Combine American Pentecostal tradition
All rely on music and dance
Emphasis on clan and community participation
Often involves dream interpretation
Focus: exorcise bad spirits
fortify the body
EPIDEMIOLOGY OF MENTAL ILLNESS IN SOUTH AFRICA
________________________________________________________________________
Xhosas Soweto (clinic) Soweto (GH)
________________________________________________________________________
Schizophrenia Schizophrenia (40%) Org. brain synd. (38%)
Depression Epilepsy (14%) Schizophrenia (35%)
Epilepsy Toxic psychosis (13%) Affective disorder (15%)
Cape Town (YA)
Toxic psychosis (50%)
____________________________________________________________________
(Toxic psychosis: uncertain diagnosis, racial prejudice as in Britain)
EPIDEMIOLOGY OF STRESS-RELATED DISORDERS IN SOUTH AFRICA (per 100,000)
________________________________________________________________________
Hypertension Ulcers Coronary Heart Disease
________________________________________________________________________
Africans (12.9) Africans > Whites >
Coloreds (14.9) Migrant workers > Indians >
Whites (21.6)
Indians (31.8)
________________________________________________________________________
Other possible causes:
Urbanization
“Western” life-style
Malnutrition
High rates of alcohol consumption
PRACTICE OF PSYCHIATRY IN SOUTH AFRICA
- Poorly served in terms of health personnel
- 1 psychiatrist per 100,000 population (5 - 15)
- 3 clinical psychologists per 100, 000 (15 - 35)
- Disparities of provision by race
(psychiatric beds: Whites 1:2500; Blacks 1:6300)
- Range of sophisticated services for Whites
- Resources in rural and poor areas more limited
- Linguistic and financial barriers still exist
FUTURE OF PSYCHIATRY IN SOUTH AFRICA
Some possible trends:
- Time of social change
- High degree of turmoil and political violence
- Western-style services
- Specialized psychiatric and psychological services
- Community-based care
- Primary health care
- Referral skills
- Amalgamation of traditional and modern approaches
Chapter 5
PSYCHIATRY IN TANZANIA
Introduction
Population:
- 27.4 millions
- Annual growth rate 2.8%
- For every 100 females 96 males
- Average household 5.3 persons
- Half population under 15 years old
Geographical distribution:
- 75% population lives in rural areas
- 8000 registered villages
- Least urbanized in Africa
- Villages provide social services
Employment:
- 80% workforce in agricultural sector
- Agriculture yields 50% GNP
- Predominantly agricultural peasant communities
Religion:
- Christians 40%
- Muslims 30%
- Indigenous 30%
Introduction Cont/d.
Emphasis:
- Unity of the world
- Sacrifices to sacred groves to ensure well-being of clans
- Oblivious to scientific and technological advances
- No distinction: animate-inanimate, natural-supernatural,
physical-psychic
- Living world and invisible world of ancestral spirits on a continuum
- Dead ancestors protect social affairs of community
- Elderly guardians of tradition and serves as link between
the living and the dead ancestors
Causes of illnesses:
- Level of education irrelevant to rationale
- Supernatural
- Mental illness
a misfortune
a penalty for misdeeds
a manifestation of an ill-omen
a curse from an ancestor
PREVALENCE OF MENTAL ILLNESS IN TANZANIA
World Health Organization (WHO) Survey
- Severe mental retardation in adults 1%
- Severe mental retardation (including cerebral palsy)
in children 0.5%
Ministry of Health Survey (1984)
Sample: 10% of Morogoro and Kilimanjaro
- 7% complained of psychiatric symptoms
- 2% psychiatrically diagnosed
- Neurosis 1.2%
- Epilepsy 0.5%
- Schizophrenia 0.3%
- Alcohol abuse 0.2%
- Cannabis abuse 0.1%
- Depression 0.1%
Reasons for low prevalence rate
(1) 10% of rural population surveyed
(2) Fears of stigmatization
(3) Inadequate diagnostic criteria
(4) Many may not seek help from health centres
SYMPTOMS OF SCHIZOPHRENIA AND PSYCHOTIC STATES IN TANZANIA
Carry social stigma of kichaa or wazima
Symptoms:
- aggression
- confusion
- paranoid symptoms
- auditory and visual hallucinations
- mutism
- negativism
- feelings of being controlled by external forces
- religious ideation and delusions
- delusions of being bewitched
- ancestral requisites (calling upon demands)
- somatization
Organic disorders often misdiagnosed as acute psychotic states
(encephalopathy, toxic agents, falciparum malaria, sleeping sickness, psychomotor epilepsy)
Possible explanation for better prognosis of acute schizophrenia in underdeveloped countries
MENTAL ILLNESSES IN TANZANIA
Depression:
- Predominated by somatic complaints
- Hypochondriacal delusions
- Mainly gastrointestinal and cardiorespiratory symptoms
Also seen in puerperal depression
Neurosis:
Most common and crippling and premorbid to other disorders
- Premorbid history of polysymptomatic symptoms
- Vague physical complaints
- Things crawling under skin
- Heat on head
- Coldness and numbness in limbs
- Choking
- Heaviness of head or chest
- Blurred vision
- Tremulousness
- Shifting headaches of varying intensity
(Causes exogenous: divorce, loss of property, illness, loss of loved one)
MENTAL ILLNESSES IN TANZANIA CONT/D.
Phobias:
- Mainly affect women - culturally men are not expected to show fear
- Common phobias
- heights
- thunderstorms
- darkness
- animals
- snakes
- ghosts
- insects (Dudu-phobia)
Organic brain disorders:
- Acute organic or confusional state
- Temporary and reversible
Symptoms:
- Disturbance of consciousness
- Loss of memory
- Disorientation, mainly to place
- Labile mood
- Insomnia
- Visual hallucination
MENTAL ILLNESS IN TANZANIA CONT/D.
Major causes:
- Severe infection (falciparum malaria, meningitis, typhoid,
H.I.V., pneumonia)
- Head trauma
- Cerebral degenerative diseases
- Tumors
- Hepatic failure
- Diabetes mellitis
- Vitamin deficiencies
- Endocrine disorders
- Anemia
- Malnutrition
Substance abuse (mainly in young, unemployed males):
- Alcohol - Cannabis
- Tobacco - Khat
- Cocaine - Heroin
- Mandrax - Benzodiazepines
- Analgesics - Solvents
Symptoms of cannabis acute psychosis
1. Auditory and visual hallucinations
2. Irritable
3. Aggressive
4. Hyperactive
5. Impulsive
6. Delusions
7. Anxiety
8. Impairment of memory
9. Panic attacks
INDIGENOUS PSYCHIATRIC DISORDERS IN TANZANIA
1. Irarata:
- Malignant severe depression in menopausal women
- Exists in the Meru tribe (Northern Tanzania)
Cause: Reactive to death of spouse
Symptoms:
- severe depression
- anhedonia, loss of will to live
- anorexia
- wish to escort dead spouse
- death within weeks or months
2. Malignant anxiety:
- Rare occurrence
- Caused by severe stress
Symptoms: social incapacitation
violence
sudden death
INDIGENOUS PSYCHIATRIC DISORDERS IN TANZANIA CONT/D.
3. Brain-fag syndrome:
- Reactive anxiety/depression in adolescents
- Usually in secondary school pupils
Cause: academic competition atmosphere
Symptoms:
- anxiety - headaches
- burning sensation - crawling feeling
- visual difficulties - poor comprehension
- poor memory - physical tiredness
- insomnia
4. Mori:
- Frequent morbid rage experienced by Masai warriors
Symptoms:
- Heightened state of aggression
- Irrational acts
- Psychomotoric excitement
- Growls with rage
- Hyperventilates
- Trembles with wide open eyes
- Froths at the mouth
(If misses target, becomes homicidal, needs to be restrained)
INDEGENOUS PSYCHIATRIC DISORDERS IN TANZANIA CONT/D.
5. Kupandisha mashetani:
- Raise demon in oneself
- Common in women of coastal regions
Cause: spirit-possession
Symptoms:
- high anxiety
- ego disorganization
- depersonalization
- dramatic bizarre behaviors (shouting, inappropriate acts)
- hyperventilation
6. Jazba:
- dissociative state occurring in a religious context
- Muslims
- when reciting prayers (emotional religious session)
- loses memory
- loses coherence
- utters unintelligible speech
MANAGEMENT OF MENTAL ILLNESS IN TANZANIA
Traditional healing
- Treated by mgangas (traditional healers)
- Holistic view of illness
- Tranquilizing herbs
- Insight into patient’s dynamics
- Medical treatment last resort
Modern approach
- Psychotropic drugs
- Antidepressants (low dosage)
- ECT
- Communal support
Chapter 6
PSYCHIATRY IN FRENCH SPEAKING WEST AFRICA
- Modern psychiatry of recent origin
- Influenced by Henri Collomb
- Non-custodial approach
- Multidisciplinary team
- Clinical Psychology service
- Research orientated
- Traditional healing among Wolof and Lebon tribes
CAUSES OF MENTAL ILLNESS IN WEST AFRICA
- Illness influenced by outside persecutory forces
- Beliefs serve as criteria for classification
- For example, 4 types of aggression:
a) involving ancestral spirits (rab, tuur)
b) involving Islamic spirits (jinn, seytanne)
c) attacks by witches (demm)
d) interpersonal magic or sorcery (liggeey)
- These beliefs shared by everyone
- Common language for therapy
- Therapeutic interpretation of pathological experiences
- Group experience
- Group responsibility
- Symbolic cure
CULTURAL CONSTRUCTION AND EXPLANATION OF MENTAL ILLNESS
Nit ku bon (person who is bad) among Wolof tribe
- Illustrates “how a culture constructs and describes, utilizes and explains
pathological entity by using its own meaning”
E.g., a nit ku bon child - labeled as a child who is bad
Symptoms:
- refusal to respond
- extreme sensitivity
- frequent crises
- violent reaction to everything
- hostility
CAUSES OF A NIT KU BON CHILD
1. Ancestral spirit visiting humans
2. Reincarnation of an ancestor
3. Reappearance of a child (mother with successive deaths)
4. An alien (acting but not reacting)
5. Ambivalence between a great future and death threat
Shows what behaviors are expected from children and how deviations from
the norms are interpreted.
PSYCHIATRIC DISORDERS DIAGNOSED AT FANN CLINIC
________________________________________________________________________
Disorders Symptoms
________________________________________________________________________
Anxiety disorders Motor or verbal agitation
Various somatic complaints
Threat of imminent death (attacks by
witches)
Bouffee delirante Similar to schizophrenia
Delusion of persecution
Open dialogue with community
________________________________________________________________________
Conclusions
1. Rate of psychosis lower than France
2. Delusion of self-accusation rare
3. Catatonic states rare
4. High level of tolerance by community
5. Good prognosis of bouffee delirante
6. Manic depression rare (predominance of manic)
7. Self-depreciation and suicidal behaviors rare
8. High frequency of somatic and hysterical symptoms
9. Differential diagnosis between depression and psychosis difficult
SENEGAL (DAKAR) STUDY OF DEPRESSION
- 20 years of study
- Prevalence of depression: 15% of psychiatric diagnoses
- Characteristics of depression:
Importance of somatic complaints
Constant presence of delusions of persecution
Rarity of ideas of worthlessness, self-accusation,
and suicidal behaviors
- 3 Types of depressive syndromes:
1) Type I : African depression
2) Type II : Western depression
3) Type III : A mixture of Type I and Type II
Conclusions
1. Gradual emergence of Type II depression
2. Somatization decreasing in intensity
3. Women somatize more
4. More “rational” delusions - less supernatural persecution
5. Guilt associated with modernity
Chapter 7
MENTAL ILLNESS IN INDIA
Lecture Outline
1. Background Information
2. Indian Approach to Understanding Mental Illness
3. Prevalence of Mental Illness in India
4. Cultural Factors in the Treatment of Mental Disorders
5. Indigenous Mental Disorders in India
Background Information
1. Population: 900 million
2. Language: very diverse
3. Religion: very diverse
4. Ancient culture very rich
- old texts
- ancient epics
- myths and legends
- customs and traditions
- folklore
5. Modernization: ancient influence unaffected
Indian Approach to Mental Illness
1. Mental illness known since pre-Vedic times
2. Psychiatry as a discipline emerged around 500 B.C.
3. Coincided with Ayurveda – a formal system of medicine
- mind as a sense organ
4. Causes of mental illness
(a) Disturbance in the 3 humours
(1) vayu (wind)
(2) pitta (bile)
(3) kapha (phlegm)
(b) Psychological and exogenous factors
(1) stress
(2) visitations by evil spirits
5. Treatment of mental illnesses
(a) rituals
(b) chanting of mantras
(c) hypnotism
(d) herbal medicine
6. Conclusions: values and traditions essential ingredients for modern
psychiatry
Prevalence Rates of Common Psychiatric Illnesses in India
_____________________________________________________________
Mental Illness Rates per 1000
_____________________________________________________________
Schizophrenia 0.9 - 5.30
Depression 1.5 – 32.9
Neurosis 1.4 – 20.0
Epilepsy 2.2 – 10.4
Mental Retardation 1.4 – 25.3
Organic Psychosis 0.6 – 1.70
_____________________________________________________________
Conclusions
(1) Marked variation of rates in different surveys
(2) Rates higher in urban population
(3) MR, epilepsy, and depression commonest in community
(4) Schizophrenia and neurosis comparable to the West
(5) Depression less prevalent than in the West
(6) More psychotics attend hospital facilities
Cultural Factors in the Treatment of Psychiatric Disorders in India
(1) Western model of psychotherapy not suitable
(2) “Cultural defenses” important to integrate
(3) Preference for active and directive psychotherapy
(4) More belief in physical and metaphysical than psychological
(5) Explanations to emphasize religion and faith
(6) Suggestions and reassurances needed, interpretations not indicated
(7) One-to-one and confidential relationship with therapist not
encouraged
(8) Psychotherapy need to be briefer, crisis oriented, supportive, flexible,
eclectic and tuned to cultural and social conditions
(9) Guru-Chela (teacher-disciple) approach suggested
(10) Religious texts such as the Gita emphasized
(11) Psychotherapy for illiterates culturally tailored and more use
of medication
(12) Paramedical and group approach recommended
(13) Yoga widely used with neurotic and psychosomatic disorders
(14) Faith healers and priests first consulted (30-60%)
(15) Hospitals seen as a place for physical disorders (mental illness
due to influence of supernatural powers)
(16) Amulets, mantras, and flogging widely used
(17) Drug treatments similar to West, but patients more sensitive
to response and experience more side-effects
Indigenous Mental Disorders in India
________________________________________________________________________
Syndromes Description Causes
________________________________________________________________________
Hysterical psychosis Acute, young females, Stress
conversion and possession
symptoms
Possession states Dissociative states, Possession by god,
verbal and motor devil, ancestral
behaviors, rural and spirit (epidemic)
uneducated poor women
Sexual neuroses Young males, discharge Loss of semen
(Dhat) in urine, impotence,
premature ejaculation,
anxiety, weakness,
hypochondriacal
Koro Penis shrinking, Masturbation
retraction into abdomen,
fear of size and shape
(in women – shrinking of
breast)
________________________________________________________________________
Anorexia nervosa, obsessive-compulsive disorder (OCD), dissociative identity disorder (multiple personality disorder) virtually non-existent.
Summary and Conclusions
(1) Western model of psychotherapy not suitable in India
(2) “Cultural defenses”
Chapter 8
ETHNIC FORMS OF PSYCHOPATHOLOGY IN ISRAEL
Introduction
1. Ethnically pluralistic society
2. Historical consciousness and rich cultural differentiation
3. Focusing on Jewish population
4. Traditional views of mental illness from the Bible,
the Talamud, and other sacred texts
5. Preoccupation with mental illness noted in Jewish mystical
literature in 16th Century, e.g., dybbuk possession
6. Three mental health regions (Tel Aviv, Haifa, and Jerusalem)
with 3 components
(a) mental health clinics
(b) psychiatric hospitals
(c) rehabilitation centres (“work villages”)
Ethnic Groups in Israel
Three main ethnic groups:
1. The Ashkenazic - from Eastern Europe (“Westerners”)
2. The Sephardic - from Asia and North Africa, Spanish origin (1492)
then spread throughout Mediterranean (“Orientals”)
3. The Arabs and other non-Jewish groups
________________________________________________________________________
The Ashkenazim The Sephardim
________________________________________________________________________
More emotional, dependent,
impulsive, concrete
More Western More traditional
Schizophrenia
Sick persons, innate and incurable Healthy, external causes, treatable
illness (self-labeling) (transmutive self-labeling)
(with length of hospitalization more self-labeling)
________________________________________________________________________
Epidemiology of Mental Illness in Israel
________________________________________________________________________
Mental disorders Demographic variables
________________________________________________________________________
Community Studies (5, 1960s and 1970s)
Emotional disorders Higher in women, lower SES, and
immigrants; ethnicity unrelated
Psychoses As for emotional disorders
Neuroses As for emotional disorders
Personality disorders Higher in men
________________________________________________________________________
Case Registry Studies (1981, 1950-1980, 70,000 cases)
(1) Rate of admission stable in 30-year period
(2) No relationship between different residential locations and
psychopathology
(3) Sex distribution almost even
(4) Almost equal proportions in immigration cohorts, cultural
background, and ethnic origins
(5) Findings at odds with community studies
________________________________________________________________________
PSYCHOPATHOLOGY IN MOROCCAN JEWISH POPULATION
- Massive immigration to Israel in 1950s and 1960s
- From Southern Morocco, Maghreb
- Heavily influenced culturally by the Arabs and the Berbers
- Currently the largest ethnic group in Israel
- Strong belief in traditional agents of disease
demons (jnun)
sorcery (skhur)
- Two modalities of demonic attack
1) External blow (tsira) - anxiety of conversion and somatoform nature
2) Internal penetration (aslai) - dissociation in the form of possession
(Tsira more prevalent - aslai more explicative)
- View socioeconomic problem as source of ailments
- Expect instrumental help from clinics, reject psychodynamic treatment
- Viewing problems externally caused reduces stigma
PSYCHOPATHOLOGY IN IRANIAN JEWISH POPULATION
- From Iran before 1948 and after the Khomeini Revolution
- “The Persian Syndrome” or Parsitis
- High rates of psychiatric morbidity
- Peculiar symptomatology
mainly somatic symptoms
misunderstood by Israeli mental health practitioners
labeled Parsitis (pejorative and stereotypical)
- Unresponsive to treatment
- Causes of “The Persian Syndrome” (Pliskin, 1987)
Iranians have different patterns of communication
Iranian society organized hierarchically
Internally sensitive and externally clever
Succumb to narahati - expression of emotion of being ill-at-ease
kept private and well-concealed
Traditional concept of the body and sickness
Confusing to biomedically trained Israeli
PSYCHOPATHOLOGY IN ETHIOPIAN JEWISH POPULATION
- 20,000 immigrants from Ethiopia 1979-1991
- Crisis of acculturation aggravated by travel ordeals to Israel
- Children and adolescents separated from parents (at risk)
- Many developed posttraumatic stress disorder (PTSD)
- Eating arrest disorder
some resemblance to anorexia nervosa
no weight phobia or disturbance of body image
Beb-Ezer (1990) unraveled the psychocultural basis
abdomen as the container of all emotions
sensation of agony and pain filled in the stomach
cannot contain the intense feeling and hence eating arrested
earlier persecutory experiences
survivor’s guilt
difficult acculturation (clash of 2 cultures)
Chapter 9
PSYCHIATRY IN SOUTH KOREA
Background Information:
- Ancient and homogenous ethnic group
- With unique alphabet and language
- Traditionally an agrarian society - 5000-year history
- Drastic transition from traditional to industrial society
- Multi-religious society
indigenous religion (worship of nature)
shamanism
Buddhism (4th century B.C.)
Confucianism (4th century B.C.)
Christianity (1794)
250 new religious cults
religious attitude influenced by shamanism
- Religion insignificant in prevalence
PSYCHIATRY IN SOUTH KOREA
Background Information cont/d.
- Korean culture (“mind”) influenced by
ancestor worship
filial piety (obligation towards parents)
family ties
special interpersonal bond (jeung)
individual and family prestige
- Indigenous concept of mental illness derived from shamanism a
traditional medicine
Shamanistic model: all illnesses caused by improper relationship
with the spirits
a) spirit intrusion
b) soul-loss
c) violation of taboos
PSYCHIATRY IN SOUTH KOREA
Background Information Cont/d.
- Traditional medicine:
body regarded as the source of problems
disharmony of internal organs (Yin-Yang) and dysfunction of organs
each organ has symbolic emotional or mental function
heart: site of pleasure, ideation, and spirit
liver: site of anger, courage and, soul
lungs: site of worry, sorrow, and inferior spirit
spleen: site of idea and will
kidneys: site of fear and energy
gall bladder: site of decision making and power
For example,
depression caused by dysfunction of liver and kidneys
anxiety caused by dysfunction of the heart
mental confusion caused by dysfunction of the heart and spleen
PSYCHIATRY IN KOREA
Background Information Cont/d.
- Treatment
each mental illness treated by treating the corresponding organ(s)
- Development of modern psychiatry
Kraeplin-oriented psychiatry in 1910
dynamic psychiatry (US influence) in 1945
biological psychiatry
- Psychiatric services
No. of psychiatrists : 1,400 (1 : 32,143 people)
No. of psychiatric beds : 1 bed to every 2,815 people
PUBLIC KNOWLEDGE AND ATTITUDE TOWARD MENTAL ILLNESS IN SOUTH KOREA
- Perceived as deviant and harmful behavior
Survey of Attitude and Knowledge
________________________________________________________________________
Disorder Attitude/knowledge
________________________________________________________________________
Dangerous paranoid schizophrenia Mental illness (83%)
Withdrawn simple schizophrenia Mental illness (50%)
Alcoholism Mental illness (34%)
Mental illness Fear (26%)
Mental illness in family Ashamed (49%)
Treatment of mental illness Family care more effective than hospital
________________________________________________________________________
SYMPTOMATOLOGY OF MENTAL ILLNESS IN SOUTH KOREA
- Causes attributed to supernatural beings and other people,
and somatization
- Somatization due to suppression of verbal and nonverbal expression of
hostility
- Two-third of patients initially present somatic dysfunction
- Depression marked by somatic symptoms
- Hysterical and conversion disorders common in female patients
- Traditional and elderly persons attribute causes to supernatural beins
(visit shaman and fortune-teller)
- Modern circles focus on sociopolitical paranoia
- Multiple health care system causes confusion
shaman : 20%
faith healing : 15%
traditional medicine : 65%
combined : 60%
EPIDEMIOLOGY OF MENTAL ILLNESS IN SOUTH KOREA
- Nationwide survey in 1986, using the Diagnostic Interview Schedule (DIS)
- Findings:
alcohol abuse and antisocial personality disorder higher in Seoul
alcohol dependence, agoraphobia, panic disorder and MR
higher in rural areas
alcoholism, antisocial personality disorder, and gambling higher
in males
affective disorders, phobias, panic disorders, and MR higher
in females
- Comparison with New Haven and St. Louis
alcohol abuse and dependence higher in South Korea
Mental retardation higher in South Korea
drug abuse and dependence lower in South Korea
Schizophrenia affective disorders, and phobias lower in South Korea
PROBLEMS OF MODERNIZATION IN SOUTH KOREA
- Collapse of traditional values
- Increase in alcohol consumption
drug abuse in youngsters
delinquency (violence, rape, kidnapping, vandalism, robbery, murder)
- Pressure for higher education (92-98% want higher education)
1991: 1 million applied for 270,500 places
annually 1 million unemployed re- not entering H.E.
conflict with parents (suicide, sabotage, depression, acting out,
“the senior syndrome”)
epidemic mass hysteria in 1979
- Daughter-in-law/mother-in-law conflict
one-third psychiatric admission
- Elderly (lonely & frustrated, role deprivation, senile dementia increased)
- Rate of psychiatric disorders increased
- Sexual deviancy and homosexuality less frequent
INDIGENOUS MENTAL ILLNESS IN SOUTH KOREA
1) Interpersonal fear (taijinkyofu)
due to traditional concern about the opinions of others
2) Fire or anger syndrome (hwa-byung)
mixture of neurotic and psychosomatic symptoms
in traditional people reacting to stress, mainly interpersonal
brief duration
3) Divine illness (shin-byung)
a possession syndrome
in prolonged neurotic, psychosomatic, or psychotic conditions
revelation in dream or hallucination to become a shaman
possessor usually a dead ancestor
cure occurs when converted into a shaman
CULTURE-RELEVANT PSYCHOTHERAPY IN SOUTH KOREA
Tao
an important cultural inheritance
philosophical teaching
aims to develop self that perceives the inner and outer world
realistically and liberates from emotional, pathological or
existential bondage
discovery of health potential
Chapter 10
MENTAL ILLNESS IN SINGAPORE
Background Information
1. An island city, 626 sq.km.
2. In South East Asia
3. Population 2.7 million (1990)
4. Colonized by Britain in 1819
5. Independent in 1965
6. Rapid industrialization in past 25 years
7. Per capita income US $10,000 in 1990 (Canada US $15,910)
8. Three main ethnic groups
(a) Chinese : 77%
(b) Malays : 15%
(c) Indians : 6%
(d) Others (Caucasians, Eurasians, and Arabs) : 2%
Psychiatric Services in Singapore
1. Only one mental hospital, Woodbridge Hospital, 2500 beds
2. University Department of Psychiatry – 28 beds in a general hospital
3. Private psychiatric hospital – 45 beds
4. Voluntary organizations
5. Traditional healers consulted by patients
Epidemiology of Mental Illness in Singapore
1. Three surveys of mental disorders in general population
2. Used General Health Questionnaire (GHQ)
- 28 items
- two-third (2/3) cutoff point
3. Prevalence of minor psychiatric morbidity : 18%
Indians : 23%
Chinese : 15%
Malays : 14%
Schizophrenia in Singapore
1. Sixty percent (60%) of all admissions
2. Seventy percent (70%) of inpatients at Woodbridge Hospital
3. The 1975 Survey of 423 First Admission of Schizophrenic
________________________________________________________________________
Demographics Frequent symptoms
________________________________________________________________________
Sex
Males : 59% Sleep disturbance : 55%
Females : 41% Talking to oneself : 43%
Laughing to oneself : 40%
Aggression or assault : 32%
Ethnic
Chinese : 80% Unconventional behavior : 30%
Malays : 9% Social withdrawal : 24%
Others : 10% “Talking nonsense” : 21%
Crying to oneself : 21%
Restlessness : 21%
________________________________________________________________________
4. Mean duration of illness before admission : 17.8 months
5. No differences between ethnic groups
________________________________________________________________________
15-Year Follow-up Data (1990)
________________________________________________________________________
Dead : 17.1%
Suicide : 9.5%
Natural causes : 7.6%
Full recovery : 30.0%
Partial recovery : 30.0%
No recovery : 40.0%
________________________________________________________________________
Conclusions
(1) Simple schizophrenics with long chronicity had poorer outcome
(2) Paranoid schizophrenics had better outcome (Malays)
Suicide in Singapore
_____________________________________________________________
Prevalence of Suicide 1894-1989 (per 100,000)
_____________________________________________________________
Before 1905 : 4-8
5 yearly rate : 10
Except 1936-1940 : 15.5
1941-1945 : 13.1
Latest Study (1980-1989)
Males : 1690 (58.5%)
Females : 1199 (41.5%)
Total : 2889
Ages 10-19 : 3.3 (increased)
Over 60 years : 72.0 (increased)
Chinese : 12.7 (mean age 47.4 years)
Indians : 13.2 (mean age 38.1 years)
Malays : 2.8 (mean age 38.1 years)
_____________________________________________________________
Main Causes of Suicide in Singapore
1. Mental illness : 29% (young adults)
2. Physical illness : 26% (elderly males)
3. Interpersonal problems : 23% (M: 25-44 years; F: 16-24 years)
4. Commonest means of suicide
(a) Younger age (Chinese and Malays) : jumping (highest in old city)
(b) Older ages (Indians and others) : hanging
(c) Indians : self-immolation, trains
Attempted Suicide in Singapore
Prevalence (per 100,000): 1971 (55); 1980 (70); 1986 (92)
Ages 20-29 : 157
Ages 30-39 : 129
Ages 40-49 : 92
Ethnic groups
Others : 238
Indians : 223
Chinese : 107
Malays : lowest
(Majority single, more neurotic, rigid, less extroverted)
Commonest causes of attempts
Relationship problems : 50%
Physical illness : 28%
Insomnia : 10%
Work problems : 10%
Financial problems : 3%
Commonest methods of attempts
Overdose : 95%
Jumping and hanging : 4%
Other : 1%
Substance Abuse in Singapore
1. Drug abuse reduced from 13,000 (1977) to 9,000 (1988)
2. Prevalence among those arrested
(a) Heroin : 91%
(b) Tranquilizers : 11%
(c) Cannabis : 5%
(d) Opium : 3%
3. Ages under 20 years : 31% (1977)
: 10% (1988)
4. Mainly from lower SES, school dropouts, and unemployed
5. Ethnic prevalence (per 100,000)
(a) Malays : 2.3 (1983) 7.0 (1988)
(b) Others : 1.2 (1983) 2.0 (1988)
6. Inhalation of volatile substances
(a) Increased from 24 (1980) to 763 (1984)
(b) Chinese : 67%
(c) Malays : 23%
(d) Indians : 9%
(e) Others : 0.2%
7. Alcoholism uncommon, but alcohol abuse increasing
(a) Chinese : 61%
(b) Indians : 39%
(c) Malays : 0%
(d) Ratio of males to females = 7 to 1
Epidemics of Mental Illness in Singapore
1. Koro
(a) Epidemic of Koro in 1969: 469 affected; M=454, F=15
(b) Mainly Chinese affected
(c) Triggered by newspaper report of people eating inoculated pigs
(d) Affected mainly the educated
(e) Linked to belief of transmission of disease from printed words
2. Hysteria
(a) Affected mainly females (F=27, M=1)
(b) Spread in three factories
(c) Experienced trance and seizures
(d) Caused by supernatural agents (jinns or hantus)
(e) Malays believe in semangat predisposition to illness
Transsexualism in Singapore
1. Increase of transsexualism sice 1972 (first reassignment surgery)
2. Some observed characteristics
(a) Unhappy childhood/school
(b) Activities and occupations of opposite sex
(c) Sexual aversion started at age 8-10 years
(d) First homosexual partner at age 16-17 years
(e) First intimate relationship at age 19-20 years
(f) Fully developed transsexual at age 21 years (M), 16 years (F)
(g) Less psychologically disturbed
(h) No heterosexual tendencies
3. Sexual reassignment surgery on 43 males
(good adjustment in 25)
4. Sex reassignment surgery on 38 females
(good adjustment in 21)
Chapter 11
PSYCHIATRY IN TURKEY
Background Information
- Known as Anatolia in ancient time
- In East Europe
- A bridge between East and West
- Cradle of a variety of civilizations
Hittites 1400-1200 B.C.
Phrygians
Ionians
Romans
Byzantine Empire (adopted Christianity)
Turks 10th-11th century (adopted Islam)
Ottoman Empire 1299-1923
Republic
- Population: 50 million
HISTORY OF PSYCHIATRY IN TURKEY
- Humane and caring approach to mental illness
- Healing temples/centres popular since 6th century B.C.
- Purification by bathing
- Fast or undertaking dietary regimens
- Healing during sleep by divine spirits
- Dream interpretations
- Prayers and sacrifices
- Music and musicians
- Avicenna founder of Turkish psychiatry in 1st century A.D.
- He discussed and described psychiatric disorders
- Recognized mania and depression as illnesses
- Wrote about mind-body connections
- Case study on “effects of love on pulse”
- 7 Mental hospitals built between 1205 and 1539
- Included highly developed care, e.g., singers and musicians
- Parallel developments of Tekkes (houses of sufic belief) all over the country
- A refuse from the corruption of society
- Practices based on religious and Sufic philosophy
- Love and unity with eternal love object
HISTORY OF PSYCHIATRY IN TURKEY CONT/D.
- First neuropsychiatric clinic in 1898
- Turkish Neuropsychiatric Society founded in 1914
- Psychiatry and neurology separated in 1973
- Number psychiatry specialists (1987):
Psychiatrists : 320
Neurologists : 372
- Number of regional hospitals at present:
Regional mental hospitals : 5
Total number of psychiatric beds : 6139
University hospitals psych. OPD : 22
Private psychiatric hospitals : 5
- Multidisciplinary team
- Rural population prefer injections
- Psychotherapy not readily accepted
- Behavior therapy becoming popular
- Treatment from hodjas regarded illegal
TURKISH BELIEFS AND ATTITUDES TOWARD MENTAL ILLNESS
- Range from traditional to scientific
- Before Islam, mental illness thought to be caused by spirits
- Islam believe in jinns, angels, and fairies
- Islamic villagers believe mental illness caused by jinns
- General belief in the “evil eye”
- General belief in sorcery
- “All goodness and suffering comes from God”
Treatment:
-Praying, especially by hodjas (priests)
- Sacrifices
- Visiting holy places
- Recital of surahs to ward off jinns
- Amulets (muskas)
PREVALENCE OF MENTAL ILLNESS IN TURKEY
- Lack of studies
Surveys
- Used ICD-9 and DSM-III-R
1980-1986 : 2% of all hospital beds occupied by psychiatric patients
- Survey of 1586 inpatients:
Psychotic disorders : 2/3
Neurotic disorders : 1/3
Males : 69%
Females : 31%
SCHIZOPHRENIA IN TURKEY
- Most common diagnosis amongst inpatients
- Most common subtype is paranoid schizophrenia
________________________________________________________________________
Differences of symptoms in urban and rural schizophrenics
________________________________________________________________________
Urban patients Rural patients
Anxious Behavioral outbursts
Tense Pressured thoughts
Rigid Depressed mood
Perseverated Somatic concerns
Depersonalized Withdrawn
Disorientated
Confused
Delirious
Deficient communication
Lapses of consciousness
_____________________________________________________________
Comparison between Turkish and American (Missouri) schizophrenics:
(1) Missouri families less willing to take patients at home
(2) Missouri families more ready to initiate admission
(3) Turkish families keen for discharge
(4) Turkish families and patients pressed for discharge at slightest
improvement
(5) Turkish hospitals face difficulties re- inpatient treatment
Turkish patients require lower dosage of neuroleptics to Americans
DEPRESSION IN TURKEY
- Prevalence rate of depressive symptoms : 20%
- Prevalence rate of clinical depression : 10%
- Risk factors associated with depression:
- over 40 years
- female
- widowed
- nuclear family
- low SES
- elderly living in nursing homes
- Symptoms in Turkish depressives
- more somatic symptoms
- mild depression less regarded as illness (traditional help)
- Medical approach more accepted in urban areas
- Suicidal thoughts common (40%)
- Low suicidal rate : 2-2.5 (Hungary: 45; Denmark: 32; UK: 10)
(Males: 35-year old, divorced, widowed)
(Females: unmarried, divorced)
ALCOHOL AND DRUG ADDICTION IN TURKEY
- Traditional drink in Turkey is the spirit raki (lion’s milk)
- Consumption of beer increasing
________________________________________________________________________
Survey of 3236 alcoholic patients in Istanbul (1985-1987)
________________________________________________________________________
Raki : 39.3%
Beer : 36.3%
Wine : 10.8%
Age drinking commenced : 15-20 years (54.3%
Drinking commenced at home : 57.9%
Cessation of drinking during Ramadan : 54.5%
Males and females ratio of drinking : 30 to 1 (M: 96.7%)
(Western societies : 3-4 to 1)
________________________________________________________________________
- Most widely abused drug : cannabis (40.2%)
Chapter 12
PSYCHIATRY IN AUSTRALIA
Background Information
1. Largest island continent
2. Most sparsely populated, 2.1 per sq. km.
3. Highly urbanized society, concentrateted in major cities
4. A federation with 3 tiers of government:
federal
state
local
5. Dominant culture rooted in British traditions and institutions
6. American influence after World War II
7. 2 core cultural values:
1) emphasis on individuation, future, and activity
2) fairness, no class distinction, cultural autonomy
8. Mental health low priority
9. Scandals re- human rights since first lunatic asylum (early 1800)
10. Enthusiasm for reform currently:
(a) improvement of services
(b) shift from monoculturalism to cultural diversity
PSYCHIATRIC SERVICES IN AUSTRALIA
1. Prevalence: Common psychiatric condition with USA ranges
2. Diagnostic tools: DSM-R and ICD-9
3. Per 100,000 population: 24 psychiatric beds
10 psychiatrists
4. Patients of state services: low SES, 50% on pensions, unemployed
5. Most admissions to state inpatients
6. Private services:
77% or psychiatric consultations
2/3 of psychiatrists
publicly funded by Medicare
1% of population consult a private psychiatrist
14% of GP consultations re- mental illness
MENTAL HEALTH SERVICES FOR MINORITIES IN AUSTRALIA
Australian Immigrants
- A nation of immigrants from over 100 countries
_____________________________________________________________
1947 1986 1991
_____________________________________________________________
7.6 m 17 m (40% to immg.)
90.2% (A-born) 79.2%
7.9%(Eng. spk) 9.2%
1.9% (non-Eng.) 11.6%
_____________________________________________________________
Point prevalence of mental disorders in immigrant communities (per 100,000)
_____________________________________________________________
Non-English speaking background (NESB) : Higher
Italy : 67.8
Yugoslavia : 65.9
Greece : 57.3
Other Europeans : 55.6
Australia : 35.7
UK and Ireland : 32.3
Asia : 28.0
Suicide
Yugoslavia : 4.41
Vietnam : 2.06
Australia : 1.14
England : 1.04
Utilization of services & self-referrals : less in NESB
Involuntary admissions : more in NESB
Psychotic disorders : more in NESB
ECT : more in NESB
Traditional healing : among NESB
MENTAL HEALTH SERVICES FOR ABORIGINES IN AUSTRALIA
Aborigines 1% of population
- occupied the continent for over 30,000 years
Contact between Aborigines and Europeans 200 years
- catastrophic for Aborigines
- life expectancy 20 years less
- infant mortality 3 times higher
- unemployment 6 times higher
- average income half
- imprisonment 20 times higher
- until 1960s Aboriginal children removed from families
Higher prevalence of psychiatric disorder and psychological morbidity
than the general population
AUSTRALIAN RESPONSES TO CULTURAL DIVERSITY
Some improvement, but much is lacking
Understanding of linguistic and cultural knowledge
60% of first year medical students, one parent non-English speaking
Federal recognition of specific cultural needs
Policy developments
Understanding of mental illness among Aborigines
Establishment of The Multicultural Psychiatry Centres
Victorian Aboriginal Mental Health Network
Services for the Treatment and Rehabilitation of Trauma
and Torture Survivors
Chapter 13
PSYCHIATRY IN BALI (INDONESIA)
Background
- Island province in Republic of Indonesia (5th largest country)
- Population about 3 million (1.5% of total)
- Equal distribution of males and females
- Chief occupation - farming
- Major religion - Hinduism
- Few changes in cultural practices and beliefs
- Balinese Hindus believe in 5 principles:
1) a supreme God
2) existence of an eternal soul - mental activity determined by soul
3) every deed has rewards or consequences (illness being one)
4) reincarnation or rebirth into the world
5) eventual unity with God
- Traditional healing influenced by above
- Newborns taken to spiritual medium healer to safeguard success in life
BALINESE HINDU CONCEPT OF MENTAL ILLNESS
- 3 factors important for well-being, happiness, and health:
1) the microcosmos: individual or soul a manifestation of God
2) the macrocosmos: the universe
3) God
- Strive to keep these 3 factors in equilibrium
- Vulnerable to illness when equilibrium disturbed
- Mental illness caused by either natural causes or supernatural factors
- Supernatural factors:
under a spell (bebai: evil spirit made by sorcerer, power from God)
witchcraft
under curse of ancestors
activity of the gods
unfavorable birth date
unfavorable or unsuitable name
poisoned by someone
suffering black magic
ATTITUDE TO MENTAL ILLNESS IN BALI
“Bali illness” (caused by supernatural factors)
spirit possession
curse of an ancestor or the gods
curable
no stigma re- supernatural causes
family disgrace re- insanity (e.g., genetic, incurable - buduh)
diagnosis changes
Changes in diagnosis by families in 113 acute psychotics
________________________________________________________________________
Diagnosis First Exam. Exam. 1 yr later
________________________________________________________________________
“Nervous illness” 64% 33%
Buduh 12% 0%
Mental illness 18% 27%
“Bali illness” 6% 33%
Don’t know 0% 7%
________________________________________________________________________
PSYCHIATRIC SERVICES IN BALI
- Treated by physicians, traditional healers (balians), and trained high priests
- 2 psychiatric hospitals: Bangli Mental Hospital: 225 beds
Chronics, 2 psychiatrists
Psychiatric Unit at Wangaya G.H. : 20 beds, acute
5 psychiatrists, 5 psych. residents, 1 psychologist
- Estimated # of balians: 2500 (73% farmers, 27% full-time)
- Approaches to balian treatment:
all balians specialize in mental problems
balians consider their work as social services
becoming balians bound by responsibility and inheritance
understand causes in terms of supernatural factors
restoration of equilibrium of 3 factors
physicians can only treat illness re- natural causes
balians first line of consultation
BALIAN TREATMENT TECHNIQUES
4 approaches:
1) use traditional Balinese teachings (45%)
2) use trance (10%)
3) function as trance mediums, possessed by God spirits (20%)
4) self-taught spiritual healing (25%)
Balian techniques:
healer and client go into a trance
white magic to counteract black magic
smoke, holy water, medicinal concoctions
prayers and chanting
special ceremonies, e.g., purification
76% seek traditional healing before referral to psychiatrist
80% of families follow traditional rituals during hospitalization
4 forms of modern and traditional integration
1) traditional healers continue treatment in hospitals
2) traditional healers refers to psychiatrists
3) hospital-leave to attend purification ceremonies
4) psychiatrists discuss traditional healing
MENTAL DISORDERS IN BALI
Uses DSM and ICD
Similarities and differences with the West
________________________________________________________________________
Uncommon/Infrequent Low rate Common
________________________________________________________________________
ADHD Juvenile delinquency Somatization disorder
Conduct disorders Schizophrenia Panic attacks
MPD (none) Suicide (trance) GAD
Bulimia (none) Acute psychosis
Anorexia nervosa (none) Bipolar disorder
Alcoholic psychosis (none) Mania
Drug abuse
Phobias
OCD
BPD
________________________________________________________________________
INDIGENOUS MENTAL DISORDERS IN BALI
1) Amok
- Sudden outburst of violence toward other people
- Involves series of behavioral, psychological and social changes
- Period of social withdrawal followed by sudden attacks
- Assaults persist for minutes to days
- Amnesic of assaults
- Caused by spirit possession or soul loss
- Killed or restrained
2) Latah
- Caused by possession
- “Fright neurosis” (primitive hysteria, arctic hysteria)
- Sudden onset after acute fright
- Echolalia, coprolalia, inappropriate behaviors
- In lower SES older women
3) Bebainan
- A trance or a dissociative disorder
- Possession by evil spirit (bebai)
- Sudden onset, lasts 15-60 minutes, in ages 16-30
- Impairment of consciousness, loss of identity, loss of motor control
- Triggers: Kajeng Kliwon, stress, exhaustion, menstruation
Chapter 14
PSYCHIATRY IN JAMAICA
Background
- Tropical island in Caribbean, 2.5 million
- Columbus in 1494 (Spanish), British 1655, independent 1962
- African descents 96% (British, East Indian, Chinese, Lebanese)
- Life expectancy 71 years, literacy 73%
- Extreme inequality, unemployment, underemployment (GNP $US 960)
- Crime a major problem
- Upper class (White) - nuclear family
- Middle class (“brown” or mulatto) - nuclear family
- Lower class (Black) - common-law
- illegitimacy
- matrifocal (mother-headed)
- legal marriage idealized (late in life)
- men and women live separate lives
- conjugal relations fragile
CULTURE IN JAMAICA
- British influence, African heritage evident
- Middle and upper class identify with West
- Lower class identify with African, Creole, or Afro-European
- Language: British English and Jamaican Creole
- Very religious
- Upper and middle classes: Anglican, Methodist, Presbyterian, Christian
- Lower class: Pentecostal churches
- Indigenous cults with African influence (Kumina, Pukkumina, Zion Revival)
- Religious worship:
- highly emotional
- encourage dramatic convulsive performances
- interpreted as divine possession
- practice spiritual healing
- illness and misfortune attributed to demonic influence
- believe in taboos, signs, spells, charms
- believe in ghosts and “obeahmen” (sorcerers)
- protected by “scientist” or “professor”,
practice “DeLaurence”
- “Rastas” believe in Haile Selassie (“Jah”)
- smoke marijuana as a sacrament
SOCIALIZATION AND PERSONALITY IN JAMAICA
- Important values: communal involvement, social interaction, spontaneity
- Lots of tension: suspicion, mistrust, envy, malicious gossips
- Men regarded as unreliable, untrustworthy, sexually obsessed
- “Extrapunitive” attitude (self never wrong)
- “White bias” (inferiority, insecurity, powerlessness)
- Dissatisfied with physical features
- “Paradox of normalcy” (family structure not patriarchal)
- Dependency to mother encouraged
- Children desired (virility, high status of motherhood)
- Family not child-centred
- Child-shifting common:
- 70% children born to fatherless families
- 63% children fostered
- 37% children experience mother-child
separation over 6 months
- 52% of school children show disturbed behaviors
- Parents domineering, authoritarian, disciplinarian
- Punishment: nagging, threat, criticism, “floggings”
PSYCHIATRIC SERVICES IN JAMAICA
- Asylum in 1938, replaced by Bellevue Hospital 1863, OPD 1948
- Services decentralized in late 1960s
- Divided in 3 psychiatric regions in 1973
- Innovative programs:
- Custodial to therapeutic community 1972
- Radio-call psychiatry 1975
- OT, carpentry, crafts, art, music, drama, chicken rearing)
- Public performances
- Reversal since 1982 (conservative government)
ATTITUDE TO MENTAL ILLNESS IN JAMAICA
- “Madness”: unusual and unintelligible behaviors
- “Madman”: a deviant (treated when troublesome, destructive, violent)
- Causes:
1) duppies: ghosts, can trouble the living
2) Obeah: sorcerers controlling ghosts
3) “nerves”: “broken nerves” by excessive stress
4) bad living: immorality can “sick” the body and mind
5) “ganja”: smoking marijuana
- Mentally ill highly visible
- Difference in urban and rural attitudes
- Lower classes get traditional healing from churches (Balm)
- “Spiritual gift”, “spiritual reading”
- Balm healers provide protection from duppies and Obeah
- Spiritual treatment: bath, prayers, candles, amulets,
“shouting” to remove “destruction”
- Spiritual healers treat mainly anxiety and depression (somatized)
PREVALENCE OF MENTAL DISORDERS IN JAMAICA
- Decrease of mental illness since 1962
- Lower prevalence rate than England
Prevalence of schizophrenia (per 100,000) in Jamaica and England
________________________________________________________________________
1971 1988
Jamaica England Jamaica England
Males 86 68 43 63
Females 52 72 26 80
________________________________________________________________________
Diagnostic profile for psychiatric admission in Jamaica (1988)
________________________________________________________________________
Schizophrenia and paranoid psychoses : 50% (higher in males)
Affective disorders : 18% (higher in females)
Other psychoses : 17% (higher in males)
Neuroses : 5% (higher in females)
Personality disorders : 5% (higher in males)
Alcoholism and other substance abuse : 5% (higher in males)
________________________________________________________________________
Suicide very low: 1.4 per 100,000 in 1975; .51 in 1988 (US: 14)
Alcoholism low: mainly in high class
Syphilis high: 20% of population
Chapter 15
PSYCHIATRY IN MEXICO
Background
- Mexicans have a rich cultural legacy
- Pre-Hispanic Aztec philosophies:
linked to ancestors, gods, and spirits - man’s place in cosmic order
influence social cohesion, cultural identity, and medicine
mind and mental functions distributed in 3 main vital centres
(1) brain, (2) heart, and (3) liver
disturbance in any centres can cause mental illness
- “Traditional illness”, or tonalli loss, or susto, “magical fright” (fright illness)
TRADITIONAL PSYCHIATRY IN MEXICO
Symptoms: anorexia, inertia, debility, nausea,
diarrhea, insomnia, nervousness,
irritability, and loss of interest
(can develop into neurosis or psychosis)
Cause: loss of soul
Treatment: “call” the lost soul and restore it to the body
(symbolic approach)
- Pathogenic winds (ehecame)
certain kind of wind may cause mental illness
some people can expel such wind (pregnant women, babies, and
adolescents vulnerable)
ihiyotl from the liver escapes and can be dangerous to others
witches can transform into whirlwinds and possess people
wind used as an invisible projectile
some supernatural beings conceived as winds
all can cause delusions and hallucinations
- Nervios (to be nervous) - another popular diagnostic entity
a “disease” of Mediterranean origin
USE OF HALLUCINOGENIC DRUGS IN MEXICO
- Ingestion of hallucinogenic drugs inherited from ancestors
- Ritual significance
specific circumstances
amount strictly controlled
careful preparation of group and individual
induction of acceptable hallucinatory experience
drug addiction extremely rare in Indian communities
ingestion without preparation lead to madness/punishment
Carlos Castaneda: The Journey to Ixlan
A Tale of Power
A Separate Reality
(These three books are suggested for students wanting to know about the Mexican Indian spirituality)
SPIRITUALIST HEALING OF MENTAL ILLNESS IN MEXICO
- Spiritualism founded by Roque Rojas in 1866
- Popular among the poor
- Illness a product of disturbed spirit by possession
- Treatment/healing:
- spirit identification
- expulsion from the body
- education of the spirit not to be affected in future
- facilitated by medium going in a trance
- facilitators supposed to be “mentally ill”
- delusions integrated into religious views
- psychoses integrated and acquire social function
- a psychiatric problem when immorality involved
MODERN PSYCHIATRY IN MEXICO
- European psychiatry introduced early (1525)
- First Psychiatric Hospital in 1567
- Mental Hospital for “mad” women in 17th century
- Ran mainly by friars
- New modern hospital in 1968 and others released from religious to civil
- Treatment like Europe but also traditional healing
Prevalence of diagnoses among psychiatric in- and outpatients
________________________________________________________________________
Inpatients (1988) Outpatients (seen by GPs)
Schizophrenia 34% Anxiety 50%
Epilepsy 24% Depression 30%
Drug addiction (1977) 2%
________________________________________________________________________
- Children utilize more services in Mexico City
- Men consult physician only when symptoms severe
Chapter 16
PSYCHIATRY IN URUGUAY
Background Information
1. Uruguayans descended from European settlers: Spanish, Italians
2. No indigenous cultures due to tribal extermination 200 years ago,
following independence from Spain
3. Some vestiges of the indigenous races exist, e.g., Carnival music
4. Democracy since early 20th century, “American Switzerland”
5. Dictatorship for 13 years (from 1973), violations of human rights
6. Serious economic problems, had the highest per capita debt in S.Am.
7. Slump caused 21% of households to sink down to poverty level
8. Country do not offer a future for young people, increasing emigration
Cultural Aspects of Mental Illness
1. Uruguayan society encourages alcohol drinking at every opportunity:
birth, business deal, any social occasion, courtship, wakes
2. Both men and women accept drinking in males, alcohol tolerance
seen as part of the “machismo” ideal
3. Problem drinking punished only in case of severe disturbance
4. Traffic rules do not allow blood or other tests for drunken driving
5. The Penal Code considers inebriation as an attenuating circumstance
6. Folk beliefs encourage positive image of alcohol, e.g.,
it is healthy
it is warming
it is a good nutrient
red wine cures anemia
a dose of liquor raises low blood pressure
it kills “microbes”
7. It is estimated that 94 liters of an alcoholic beverage are consumed
per capita in the over 15 years of age (ratio of M to F: 1 to 20)
8. Using Jellinek’s Formula (i.e., the hepatic cirrhosis death rate ratio),
1354 alcoholics with medical complications were found for every 100,000 inhabitants
9. Currently alcoholism is increasing in younger people and in women
Beliefs of Mental Illness
1. Popular etiology based on natural causes of mental illness,
although psychic stress is emphasized
2. Congenital factors, toxic substances (alcohol, drugs), and lack
of nourishment also seen as important
3. Psychotropic drugs are the most popular form of psychiatric treatment
4. Supernatural causes seen as less important and may include
breaking a taboo or a moral rule (eating something evil,
getting wet, or behaving improperly),
sorcery, witchcraft, fate
5. Folk healers punished by the law, but has contact with population
6. Herbal or praying curanderos treatments are common
7. Role of new religious sects (Afro-Brazilian cults, Pentecostals)
increasing in crisis management
Prevalence of Mental Illness in Uruguay
1. Alcoholism subject of research in 1968, found higher incidence
of mental disorders among alcoholic families
2. Alcoholism represents 30% of male psychiatric admission
3. Suicide rate highest in Latin America (1990)
1960: 12.7 per 100,000
1987: 8.7 per 100,000
Predominantly males: 70-80 years old, violent methods
50% psychiatric illness
Preponderance females: 20-30 years old, overdose
4. Survey (1985) of 9223 private patients
High percentage of depression
Unipolar depression in upper class (52%)
Bipolar depression in 1%
Schizophrenia made up of 25% of diagnoses
Prevalence of Mental Illness Cont/d.
5. University Psychiatric Ward Admission Survey (1950-1960)
Schizophrenia: 11%
Paraphrenia: 1.8%
Paranoia: 0.5%
Bouffee delirante: 5.7%
Increase in paranoid and schizoaffective disorders
Decrease in catatonic schizophrenia
Decrease in conversion symptoms in somatoform disorders
6. Anorexia nervosa and bulimia increasing
7. Multiple personality disorder (DID) nonexistent
Culture-Specific Syndromes
Four culture-specific syndromes reported
1. Nervios (nerves), form of anxiety disorder, characterized by:
insomnia restlessness
bad temper sadness
loss of appetite weight loss
crying loss of libido
2. Ataques de nervios, neurotic or stress disorders, more acute
Symptoms as nervios, but with strong psychomotor
components
3. Enloquecer (“to be driven insane”, psychotic), symptoms include:
babbling acting odd
aggression speaking or laughing when alone
screaming or crying noticeable looks
4. Mal de ojo (evil eye), often restricted to child victims, symptoms
include:
headache sleeplessness
drowsiness fever
fixed stare digestive disturbances
Mal de ojo pasado, severe form of mal de ojo, usually ends in death
Psychiatric Services in Uruguay
1. The first Asylum (28 beds), in French style, was built in Montevideo
in 1860, still operational
2. University psychiatry began in 1908 by Etchepare
3. He was educated in Paris, propagated French Psychiatric tradition
4. ICD widely used, DSM used for scientific papers
5. Influenced by psychodymanic movement since 1956
6. Close liaison with the legal system since 1838
7. Community mental health approved in 1986, children unit
opened in 1990, no special programs for the elderly (16%)
8. Psychopharmacological treatment favored, but hospitals rejected
9. ECT widely used, referred to as the “sleeping cure”
10. Psychotherapies used in private practice
11. Herbs widely used
12. Folk healers not encouraged
Chapter 20
MENTAL ILLNESS IN CZECH AND SLOVAK REPUBLICS
Background Information
1. Long history of psychiatry and care for mental illness
2. Psychiatric Department started in the Czech University Medical
School in 1886
3. Psychiatry and Neurology developed independently
4. Territories of both republics parts of Austro-Hungarian Empire before
World War I
5. Czech lands belonged to industrial Austria
6. Slovak lands belonged to feudal Hungary
7. Psychiatric care provided mainly in inpatient facilities
a. Czech psych. care based on Austrian model (large asylums
outside larger towns)
b. Slovak psych. care based on Hungarian model (integral part
general hospitals, concentrated around Budapest)
8. After World War I Slovakia broke away from Hungarian rule,
mental asylums damaged/destroyed during World War II
9. The two countries have different history of care and structure
10. Influenced by German, Swiss, and French psychiatry
11. Three decades ago replaced by Leningrad and Moscow psychiatry
12. Last decade interest in ICD and DSM
Similarities and Differences Between the Czech and the Slovak Republics
_______________________________________________________________________Similarities Differences
_______________________________________________________________________
Understand both languages Availability of services
Gypsies dispersed Czech population twice of Slovak
Historically and culturally different
Catholic majority in Slovak Republic
Protestant majority in Czech Republic
Communist Party persecuted religion
German minority in Czech (left 1945)
Hungarian minority in Slovak (exist)
________________________________________________________________________
Psychiatric Morbidity
1. Same problems as other European member states
2. Increase in old age, increase in mental illness
3. Epidemic rise in alcohol dependence and abuse
4. Epidemic rise in abuse of psychoactive substances
5. Epidemic increase in psychiatric morbidity in general
practice/primary care
6. Need for internationally comparable psychiatric information system
Epidemiological Information
1. Survey based on 20% sample of insured sick leave
2. Administrative form include ICD diagnosis and signed by physician
3. Decrease in neurosis since 1970 in both sexes
4. Rise in substance abuse, dependence, and induced psychosis
5. Substance abuse comprises of one-third of total sick-leave payments,
alarming development
6. First time inpatient admission for substance abuse (1963-1988)
(a) Males : increase of about +100%
(b) Females : increase of about +800%
(c) Rise in organic brain syndromes in 60+ age group
7. Alcohol abuse presents much greater problem
Suicidal Behavior in Czech and Slovak Republics
1. Decrease in suicide rate during World War I
2. Decrease in suicide rate during World War II (German minority
leaving in 1945 might have affected figure)
3. Steady decrease of fatal suicide to 1989 (last date reported in text)
4. Fatal suicide higher in males
5. Fatal suicide higher in Czech Republic
6. Highest fatal suicide in the 70+ age group
7. Highest attempted suicide rate in 15-19 age group
8. Massive reduction in suicide attempts (comparing 1979 to 1989)
Macrosocial Stress Induced by the Warsaw Pact Forces
1. Macrosocial stress: a “situation when large population groups
are exposed to massive stress load”
2. Such situation took place when Czech Republic was occupied by
Warsaw Pact Forces during 1968-69
3. Shared trust and favorable political orientation replaced by
disappointment and helplessness
4. “Natural experiment” studied impact on mental illness
(a) Decrease in suicide rate (interest in political activity)
(b) Increase in neurotic symptoms
(c) Reduction in work output and work motivation
(d) Some increase in depressive symptomatology
(e) Little influence in the course of schizophrenia
(f) Specific suicidal behavior – self-burning (29, unusual)
Chapter 18
Mental Illness in Greenland
- Pre-colonial population mainly Inuit (Eskimos)
- Their ancestors migrated from Western Arctic 1000 years ago
- Three stages of colonization and Christianized by Danes
(1) Western Greenland: trade mission station (1721)
(2) East Greenland: declining tribe, discovered in 1884
(3) North Greenland: trading station in 1910
- Explorers and whalers brought modern goods, dependence
- Population: 54,000, 45,000 native Greenlanders
- Living in 126 villages and towns, along coast 4000 km
- Contemporary population mixed with Europeans
- Language: Greenlandic (Alaskan Inuit), 3 main dialects
- Role of men and women becoming ill-defined
Traditional Inuit Mental Illness
(1) Caused by transmigration of souls
- a soul can leave physical body
- foreign soul can occupy body
- due to sorcery or violation of a taboo
- treated by Shaman
- Shaman communicates with spiritual world
for diagnosis and treatment
- complete confession
- witch or sorcerer too conduct treatment
- witch endowed with supernatural power, feared
- delirious or isolated persons seen as witches
(2) Severe psychotics abandoned, tied up, even killed
- not from cruelty, more from fear
(3) Pibloktoq, dissociative-type reaction, gradually diminished
DEVELOPMENT OF MODERN PSYCHIATRY
(1) Late 19th century Danish government built local health service
- responsibility for disturbed patients
- European ideas, diagnosis and treatment imported
- In 1950s intensive modernization, referral to Denmark
- No attempts to combine European and traditional
- Demarcation too wide now to bridge gap
- isolated areas practiced traditional care
(2) Modern general health service divided into 16 districts
- first psychiatric ward (25 beds) opened in 1980
- caters for short-term admission and outpatient
- mental hospital in Denmark
- a high-security ward in Denmark
- emphasis on local community care
EPIDEMIOLOGY OF MENTAL ILLNESS
(1) Lack of studies
(2) Health service statistics: used ICD-8 (1984-1988 admissions
in Greenland and Denmark
__________________________________________________________________
Diagnosis Male Female
__________________________________________________________________
Schizophrenia 161 47
Manic-Depressive Psychgosis 35 66
Organic Psychosis 15 12
Reactive Psychosis 64 75
Neuroses 18 68
Personality Disorder 75 77
Alcoholism 120 112
_____________________________________________________________
(3) Conclusions
(a) Sex differences
(b) No sex difference for personality disorder
(c) No cases of eating disorder
(d) Puerperal psychosis uncommon
CULTURE-SPECIFIC SYNDROMES
(1) Pibloktoq (a mad dog), almost obsolete, feared
- unconscious withdrawal from stress
(2) Qivittoq, (transformed into a ghost), feared
- permanent leave of society in anger, live in isolation
- still exist, when people disappear without trace
- more prevalent in West Greenland
- runaways during colonial period
(3) Nangiarneq (anxiety in kayaks and at edge of abysses)
- a phobic state in West Greenland
- end of 19th century affected 11-15% of active hunters
- Gussow (1963) draws similarity with jet pilots anxiety
- narrowing of sensory inputs, adaptation to stress
- intentional social withdrawal, going qivittoq, suicide
(4) Traditional society accepted, approved suicide
FUTURE DIRECTIONS
(1) Research needed
(2) Modern Greenland raise concerns
(a) High alcohol consumption
(b) High rate of male suicide (500-600/1000,000)
and homicide
(c) Increasing violence
(d) Increase in sexual abuse
(e) High rate of inpatient schizophrenia in men
Chapter 21
MENTAL ILLNESS IN HUNGARY
Background Information
1. Traditionally stratified and differentiated in many dimensions
2. Before World War I as part of Austro-Hungarian Empire
3. Multinational – Slovaks, Romanians, Serbians, Rutenians,
Gypsies and Jews from Russia and Poland
4. !920 Empire dissolved, divided into many countries
5. Hungary became a small homogeneous population (11 million)
6. Partition lost national identity, discrimination and suppression
from other new states, low national self-esteem
7. Main reason for Hungary joining Second World War
8. Ethnic subcultures
(a) Social class strata
(b) Germans diligent workers, main labor force
(c) Slovaks and Romanians migrant unskilled workers
(d) Jews dominated commerce, banking, and entrepreneurial
Background Information Cont/d.
9. Predominantly Christian, re-conversion from Protestant
10. Protestant ethic characteristic of Hungarian peasant
11. Church-going encourages social integration
12. Priests have high moral authority, agents of social order
13. Agricultural country, largely peasant in villages, Hungarian lowlands
14. Large part live in hamlets throughout large areas
15. Peasant culture – rigid, traditional labor, sex roles, parenting
16. Rules and norms enforced strictly, deviation not tolerated, rejection
and ostracism
17. Social exclusion seen as severe punishment, lead to suicide
Suicidal Behavior in Hungary
1. Suicide encouraged in Hungary, part of the culture
(highest recorded rate in the world: 43-45 per 100,000)
2. Strong family and community pressure to commit suicide
3. Girls pregnant out of wedlock jump into pits
4. Servants from rural areas, when in conflict in towns, poisoned with
phosphorous from safety matches, natron lye
5. Men who fail in business or social life jump from bridges
and high places
6. Soldiers shoot themselves
7. Elderly alcoholics and ill men hang themselves
8. Hanging main method of suicide for rural old people,
gradually superseded by overdose and pesticides
9. Regional differences in suicide rates, constant over 100-120 years
10. More frequent in southern and southeastern counties (65-67
per 100,000 in 1980s; approval, acts of protest against
oppression)
11. Decreased rates in the west and north (20-25 per 100,000 in 1980s)
National Characteristics in Hungary
1. Characteristics of Hungarian “soul”
(a) Hard work and obedience
(b) “Sad” behavior, “sad like a Hungarian” (plays a role in suicide,
alcohol abuse, depression under-diagnosed)
(c) Regional identity, rigid district, county and administrative
structure
(d) Strong pressure on children to achieve, lead to perfectionism,
ambition, hard-striving, competitive character
(e) Exhaustion, low self-esteem in face of minor frustration
and failure
(f) Helping and supportive behaviors not developed
(g) Even in times of crisis Communist regime suppressed
community support
(h) Hungarian language poor in expressing feelings and
relationships
(i) Therefore poor communication in crisis or relief tension
(j) Important factor in suicide, divorce, and Hungarian neuroticism
Hungarian Culture and Neurosis
1. Neurotic symptoms and complaints commonly adopted and accepted
2. However, neurotic persons are devalued and under-productive, less
competitive
3. Due to Western influence downward trend in urban areas,
encouraging self-esteem, social performance, and ambition
4. 50% of peasants moved to towns and became industrial and
public services workers
5. 50% of the population changed residence and occupation in 1960s
and 1970s
6. Rapid changes disrupted family relationships and individual
orientation
7. Original peasant subjective culture unadaptive to process
of social transformation
8. Unable to cope with adaptational and relational problems and failures
9. Lacking models for urban life, aristocracy and bourgeois persecuted
10. Prepared the way for rapid Western models of behavior
e.g., consumerism, “sexual revolution”, fashion, etc.
11. Impacted on family: high divorce rate, increase in child
psychopathology, e.g., conduct disorder, substance abuse
12. Psychiatric problems exacerbated by lack of mental health facilities
Hungarian Culture and Neurosis Cont/d.
13. Mental health profession has low prestige, extreme views
14. Biological and administrative stances preferred
15. Professional help and voluntary agencies inadequate
16. “Psychoboom” now emerging
17. Common psychiatric disorders:
(a) Organic syndromes due to poor diet, alcohol, smoking,
poor medical care
(b) Psychosomatic disorders, treated biologically, poor prognosis
(c) Schizophrenia, delusions of grandeur (aristocrats)
18. Strong stigma to mental illness, no supporting agencies
19. Mental health services
(a) Two mental hospitals
(b) Units in general hospitals
(c) Some outpatient facilities
(d) New Age of psychotherapy evolving
Chapter 22
MENTAL ILLNESS AMONG AMERICAN INDIANS AND ALASKA NATIVES
Background Information
1. American Indians and Alaska Natives are the fastest-growing
minority group in U.S., 1.4 million in 1980
2. Alaska Natives include the Alaskan Indians, the Aleuts, and the
Eskimos
3. Divided into diverse culture and language groups
4. About 40% resides on Indians reservations (land set aside for
certain groups, with limited legal and political sovereingnty)
5. About 60% live in urban, non-reservation areas
6. No political, cultural, or language unification
7. 9-17 distinct culture areas or regions identified
8. 250 tribes officially recognized by U.S. Federal government
Background Information Cont/d.
9. Excessive demoralization and severe identity problems due to:
(1) history of conquest
(2) political subjugation
(3) elimination of subsistence bases
(4) relocation into small and poorest areas
(5) forced migration in 19th century
(6) “Trail of Tears” – expelled from Southeast to unfamiliar
regions
(7) economic exploitation
(8) forced assimilation
(9) devaluing Native cultures
10. Predominantly extreme low-income, high stressed population
11. High rates of mental and physical problems
Epidemiology of Mental Disorders
1. No data on major mental disorders, except alcohol and drug abuse
2. General impression: impacted by mental illness as the
majority-culture
3. “Binge” drinking typical of “some” Indian drinkers
4. High mortality rates, medical complications, accidental injuries,
and suicide due to excessive drinking
5. Alcohol and drug abuse a serious problem among youth
6. Prevalence of inhalants (gasoline, paint thinner) among Indians
ages 12-17 twice as high as U.S.
7. Very toxic, causes serious neuropsychological sequelae
8. Suicide rates 2.3 to 2.8 times as U.S. rates, especially in 10-24 yrs old
9. Occasional reports of cluster suicides
10. Majority of suicides precede alcohol drinking
11. High rates of parasuicides and quasi-suicidal behavior
Indigenous Mental Disorders
1. Several mentioned
(1) Windigo psychosis (a giant man-eating ogre)
(2) Pibloqtoq (arctic hysteria)
(3) Soul loss
(4) Spirit intrusion
(5) Ghost sickness
2. Several therapy approaches based on traditional methods
(1) the four circle (for analysis of relationships in one’s life)
(2) the talking circle (as a form of group therapy)
(3) the sweat lodge (a healing and cleansing ceremony)
(4) the spirit dance
Treatment Systems
1. Mental health services provided by
(a) Private agencies, private practitioners
(b) Bureau of Indian Affairs (BIA), serves as referral agency
© Urban Indian Health Programs
(d) Tribal health departments
(e) Indian Health Service (IHS), provides services for reservations,
purchases contract services, especially inpatient care,
but unavailable in most areas
2. Reservation communities legally empowered to assume responsibility
for health care and services
3. Tribal-based health care programs negligible
4. Some cities have private nonprofit Indian services, funded by HIS
5. Federal community mental health centres underutilized
Service Utilization
1. Indians and Alaska Natives under-utilize services for alcohol
abuse and dependence
2. Similar under-utilization for other major mental illnesses
3. Higher discharge rates for mental disorders and alcohol psychosis
4. Alcohol-linked mortality rates over 4 times the rate for all races
5. Low hospitalization rates may be due to
(a) lack of HIS hospitals in some areas
(b) lack of funds for contract health care
© in urban areas may have no health insurance (2/3 in Arizona,
87% in Boston)
(d) Geographical barriers (more than 30 minutes travel time)
Past and Future Research
1. Research on Indian people discouraged
2. Exploited by academic researchers, for academic advancement,
not for the benefit of the Indian communities
3. Reports of mental illness and alcohol consumption reinforce
such stereotypes as the “drunken Indian”
4. Collaborative research with communities suggested
5. Politics of funding agencies
6. Lack well-validated assessment measures for research
7. Sampling problems, tendency to use convenience sampling
8. Efficient delivery of services required, remote and isolated areas
9. Priority research: prevention of substance abuse, suicide prevention,
and psychopharmacological trials
10. Integration of indigenous healing
Chapter 23
MENTAL ILLNESS AMONG THE NEW ZEALAND MAORIS
Background Information
1. New Zealand, island near Australia, shares Western values,
population of 3.1 million
2. Maoris, indigenous population, whose ancestors arrived in epic
voyages 6 or 7 centuries ago from elsewhere in the Pacific,
form 12% of population (half million)
3. Maori society undergone marked changes from contact with
missionaries, whalers, and settlers from GB, US, France
4. New Zealand annexed to Great Britain in 1840 by Treaty of Waitangi
5. New social and economic systems produced good and bad influences
6. Conflict and land wars in 1860s, left many tribes impoverished,
new settler government paved way for English immigration,
disregarded the Treaty
7. Health and social policies did not recognize Maori views, they were
considered counterproductive
8. The Tohunga Suppression Act (1907) outlawed native healers
9. Death from TB was cited as the main reason, but itent was to
totally denigrate Maori views on health and illness
10. Health professionals trained in Western medicine replaced tribal
elders as leaders of health, regulating Maoris to passive
consumer roles, culturally alien, thus skeptism
Background Information Cont/d.
11. Over past 2 decades significance of Maori culture reassessed,
concepts of tapu, noa, makutu, and tohunga revived
12. Maori population relatively youthful, in 1986 34% under 15 years
13. A tribal nation, now predominantly in urban areas
14. The shift from rural areas started in 1945
15. Caused tribal and family alienation, and social upheaval
16. Poor, income levels lower than non-Maoris, 68% children born in
even poorer families
17. Maori unemployment is 3 times higher, especially in 25-year-olds,
associated with agriculture, forestry, and fishing
18. Lower standards of educational achievement in Maori children
19. High Maori imprisonment rates, for males 13.8 times greater
than non-Maori equivalent (186 per 10,000 in 1986)
20. Mortality and morbidity show similar disparities
Infants death from SIDS : 2 times higher
Female death, 25-64 years : 2 times higher
Death after 65 years 34% : 71% in non-Maoris
Life expectancy after birth : 7 (M), 8.5 (F) yrs shorter
Traditional Attitudes Toward Mental Illness
1. Traditional Maori (pre-European) health system – integrated
approach to physical and mental health
2. But considered spirituality (taha wairua) and cognition and emotion
(taha hinengaro) to affect behavior and well-being
3. Strongly believed in the power of mind and vulnerabilities to deities
4. Insight into Maori views of behavior and sickness requires
understanding of several concepts: tapu, noa, and tohunga
5. Tapu refers to special buildings, articles, and persons
(a) require respect, cautious approach, often avoidance
(b) not necessarily a permanent state
© usually conferred by particular reasons
(d) ensure maintenance of tribal integrity and personal safety
(e) can be removed when no longer necessary
(f) breach of tapu leads to misery, sometimes death
(g) violation of tapu seen as major cause of illness
6. Noa, e.g., food, in contrast to tapu, can be approached without fear
of misfortune, but caution required to keep tapu and noa
objects apart
7. Tohunga
(a) a leader skilled in tribal lore and ancient incantations and
rituals
(b) combination of priest, physician, judge, skilled observer,
and astute politician of tribal society
Classification of Traditional Illness
1. Two clasification of understanding of illness
2. First one based on etiology
(a) distinguihes between accidents the illness of the gods
(mate atua), i.e., illness without external causes
(b) all mate atua caused by tapu
© diagnoses conducted by tohunga
(d) determines of circumstances of a breach of tapu
(e) so that appropriate amends could be made
(f) mate atua can also be caused by makutu (incantations of
tohunga from a distance)
(g) makutu can produce serious diability, without intervention
from another tohunga, can results in death
(h) health or illness of one being can be a symptom of other being
3. Second classification based on symptom clusters
(a) can include mental illness
(b) mental illness, a subset of the wider mate atua classification
Contemporary Manifestations of Mental Illness
1. Statistics for prevalence of mental illness among Maoris very recent
2. Since 1962 Maori admissions to psychiatric hospitals have increased
3. Prior to 1960 non-Maori admission rates were higher, by 1974
the situation was reversed
4. First psychiatric admission for Maoris highest in 20-29 age group
(yearly average rate for Maoris 285, for non-Maoris 220)
5. Difficult to determine accurate prevalence rate due to
(1) No formal Western or Maori diagnostic criteria used
(2) Data available from hospital admission
(3) Illness caused by makutu or tapu seen as unrequiring hospitals
(4) Communities have different levels of tolerance
(5) Socioeconomic factors, acceptance of abnormal behavior
as norm among the poor
(6) High rates of mental illness in prison and Child Health Campus
(a) 26% of all hospital patient
(b) 1/5 of all first admissions referred by law
enforcement agencies
© refusal of admission to those requiring security
(d) 67% of special patient admission (1986)
(7) Less resource to primary care (GPs)
6. Alcohol dependence and abuse leading cause of inpatient care
7. Alcohol dependence and schizophrenia overrepresented
in Maori admissions
Suicide Among the Maoris
1. Maori suicide rates lower than non-Maori rates, gap closing
2. Survey of 1973-1984
_______________________________________________________
Maoris Non-Maoris
_______________________________________________________
(a) Males : 47, first 6 years 280
67, second 6 years 173
43% increase
(b) Females : 14, first 6 years 78
22, second 6 years 100
57% increase
_______________________________________________________
Depression and Stress-Related Disorders Among the Maoris
1. These disorders hardly featured before 1970
2. A Study in 1984 reported depression as the most significant
symptom among women
3. Associated with obesity, alcohol and drug abuse, poor physical
health, and lack of tribal support
4. Contrasting with non-Maoris, anorexia nervosa and bulimia
are non-existent among the Maoris
5. Maori women both heavier and obese than non-Maori women
(3/4 overweight; ½ obese)
Indigenous Mental Illness Among the Maoris
Mate Maori
1. An illness, like mate atua, caused by spirits, following
infringement of tapu or afflicted by a makutu
2. No specific cluster of symptoms (onset sudden), may include
psychomotor retardation
depression
high levels of anxiety
insomnia
withdrawal
3. Could be mental or physical
4. Families reluctant to discuss mate Maori in hospital, fear of ridicule
5. Intervention by a tohunga necessary
6. Tohunga treatment include
(a) family as well as the patient
(b) karakia (prayers, incantations)
© immersion in wai tapu (water from a special stream)
(d) some acts of restitution
(e) use of herbs
(f) whakamanawa (reassurance and support)
7. Many tohunga distinguish between Maori and Pakeha (non-Maori)
components and advise accordingly
8. If tohunga cannot heal, referral to medical treatment
9. Treatment often carried out concurrently by physicians and tohunga
Conclusions and Future Directions
1. Socioeconomic disparities should be reduced
2. Mental illness should be understood in context of Maori culture
3. Four approaches advocated to ensure greater Maori participation
(a) Increment of Maori personnel
(b) Inclusion of Maoris in policy making
© Creation of special units using tohunga and karakia
(d) Adoption of biculturalism
Chapter 24
MENTAL ILLNESS AMONG MINORITIES IN BRITAIN
Myths Related to Minority Ethnic Status
(1) Britain is over-flooded by immigrants
- More people leaving Britain, less immigrating
(2) Britain flooded with visible immigrants
- More Irish, Jewish, and European immigrants
(3) Mass immigration cause social problems
- Not over-utilizing welfare and health services disproportionately
(4) Asian and West Indian immigrants undergo heavy psychological distress
Myth perpetuated by British Commission for Racial Equality (CRE) Report
Aspect of Mental Health in a Multi-Cultural Society (1978) based findings on
unsound methodology
Reported all non-White native unborn immigrants at risk
(5) Those immigrants originated from Caribbean and Indian subcontinents
carry excessive psychiatric morbidity
(6) “Asian” and “black” immigrants are alike
Recent Surveys in Britain
(1) Rates of Admissions to Mental Hospitals in 1981 (all diagnoses) per 100,000
________________________________________________________________________
Country of Birth Male Female
First Subsequent First Subsequent
________________________________________________________________________
England 95 225 127 358
Ireland 272 751 269 898
India 84 226 97 234
Pakistan 70 146 106 123
Caribbean 111 391 105 484
Hong Kong 47 96 87 116
________________________________________________________________________
Findings
(1) White Irish-born immigrants have highest rate of admission
(2) Caribbean-born immigrants have higher rates than those at “home”
(3) Asian-born immigrants had lower rates
Recent Surveys in Britain Cont/d.
(2) Rates admissions by selected diagnoses (per 100,000)
________________________________________________________________________Country Schizo. & Paranoia Depression Neuroses Alcohol Abuse
of birth
Male Female Male Female Male Female Male Female
________________________________________________________________________
England 61 58 79 166 28 56 38 18
Ireland 158 174 197 410 62 111 332 133
India 77 89 68 118 22 27 73 8
Pakistan 94 32 68 96 15 47 6 1
Caribbean 359 235 65 152 6 25 27 9
Hong Kong 65 50 12 75 16 29 4 8
________________________________________________________________________
Findings
(1) Irish immigrants have highest rates, except for schizophrenia
(2) Non-Whites highest rate for schizophrenia, but lower rates for depression
and neuroses
(3) High rates of alcohol abuse in Indians reflect high drinking by older Sikh men
(4) Highest rate of schizophrenia in Caribbean-born, especially for < 35 years old
Recent Surveys in Britain Cont/d.
(3) Possible Explanations for High Rates of Schizophrenia in Afro-Caribbean
(a) The “Ethnic Density” Hypothesis
(1) Inverse correlation between incidence of schizophrenia in an ethnic
group and the size of that group relative to total population
(2) Rates of schizophrenia in other minority ethnic groups provided
no support
(3) Relative size of Afro-Caribbean in other parts of England provided
no support
(b) Demographic Differences Between Blacks and Whites
(1) Not supported
© High Rates of Schizophrenia concentrated in West Indies
(1) Higher rates in immigrants than those at “home’
(2) Not supported
(d) Schizophrenia Predispose People to Migrate
(1) Afro-Caribbean enjoy stable economic improvement
(2) Not supported
(3) Possible Explanation for High Rates of Schizophrenia in Afro-Caribbean Cont/d.
(e) Migration Stress and Culture Shock
(1) Stress-related disorders not prevalent
(2) Similar stress experienced by other minority ethnic groups
(3) Schizophrenia least responsive to stress
(4) Not supported
(f) Misdiagnosed by Psychiatrists
(1) Some evidence in support
(2) Diagnosis of schizophrenia problematic, diagnosis often changed
(3) Blacks more often have initial diagnosis of schizophrenia than Whites
(4) In Western culture, hallucinations and delusions seen as indicative
of schizophrenia
(5) In other culture they may not be pathological
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